Tackling Toddler Obesity Through a Pilot Community-Based Family Intervention

By Wolman, Julia Skelly, Eleanor; Kolotourou, Maria; Lawson, Margaret; Sacher, Paul

Abstract The lack of effective child obesity intervention and intervention prevention programmes is an increasing concern for public health professionals. Since eating and physical activity habits become established in the early years, these efforts should start as early as possible. A pilot programme, Fighting Fit Tots, was developed within a local Sure Start area. It consisted of 11 weekly parent and toddler physical activity sessions, followed by a parent/carer healthy lifestyle workshop. Fighting Fit Tots was modelled on The MEND Programme, a successful community-based obesity intervention for school-aged children. Toddler recruitment criteria were based on the children’s age, body mass index and parental obesity status. It was noticed that uptake and attendance were unsatisfactory due to poor parental perception of child weight status, commitment issues, and limited staff capacity for outreach work. Therefore, the group was extended to all families with a toddler and this proved more successful. The pilot was a promising experience, and more community practitioners should be encouraged to adopt and improve a public health approach to obesity prevention in the early years.

Keywords

Obesity, toddlers, healthy eating, physical activity, MEND.

Community Practitioner 2008; 81(1): 28-31

Introduction

The global number of overweight and obese children has more than tripled in the last 30 years1. The situation in the UK has been equally discouraging – current statistics show upward trends in body mass index (BMI), and about one in three boys (30.5%) and one in four girls (27.7%) aged two to 10 years are overweight or obese2.

In the short-term, childhood obesity has been linked with respiratory and orthopaedic problems, as well as gastroenterological, endocrine and cardiovascular complications. Furthermore, the impact of obesity on the psychological status of the child encompasses features such as low selfesteem, low self- confidence, social isolation and bullying. Finally, long-term health consequences of obesity include increased risk for heart disease, hypertension, diabetes and cancer 3.

An overweight child has a 40% to 70% chance of becoming an obese adult4. Children’s eating and activity patterns become established during the pre-school period when selection of food and control of energy intake are largely shaped by parents. Parents or carers should, therefore, be involved in early intervention programmes and given appropriate advice and support to make the necessary lifestyle changes for their family.

One example of an effective child obesity intervention involving the whole family is The MEND Programme (Mind, Exercise, Nutrition… Do it!) for 7-13 year olds5. This 10-week programme consists of twice weekly after-school sessions, attended by at least one parent or carer per child, and combines physical activity, dietary education and behavioural modification.

Positive health outcomes from the MEND rando-mised controlled trial included reduced waist circumference, decreased body mass index and improved confidence6. Although this, and a number of other obesity interventions are available for school-aged children, there is very little evidence of intervention and prevention programmes targeting the early years. Fighting Fit Tots was, therefore, modelled on the successful MEND Programme, with adaptations for the younger age group.

Programme development

Fighting Fit Tots was co-ordinated jointly by the community nutritionist and health visitor working for Sure Start Larkhall in Lambeth, South London. The programme was developed in partnership with the MRC Childhood Nutrition Research Centre at the Institute of Child Healdi (ICH), University College London.

Funded by Sure Start Larkhall, Lambeth PCT, Fighting Fit Tots consisted of 11 weekly two-hour afternoon sessions, held between 1pm and 3pm. Two rooms in a local community centre were required one for parent and toddler physical activity sessions, followed by a parents’ workshop, and the other room for a creche.

Each week started with a 45-minute structured activity session facilitated by the Sure Start fitness instructor, who teaches exercise to young children in local early years settings. Parents and carers were encouraged to join in with the activities, which were mainly jumping, skipping, hopping, dancing and singing to popular children’s songs and music.

The weekly activity sessions were followed by a 15-minute refreshment break of fruit and water, after which the children were cared for in the creche while the parents engaged in a 45-minute healthy lifestyle workshop facilitated by the nutritionist and die health visitor (see programme outline below.

The intervention was planned as a closed group with places for up to 12 parent/ carer-toddler pairs. Families were eligible to participate if they met the recruitment criteria shown in Box 1.

A flyer was produced to publicise the programme to local families. It was agreed that the terms ‘weight’, ‘overweight’ or ‘obesity’ should not be used, as this could create negativity and discourage potential participants. The programme was named Fighting Fit Tots to incorporate the physical activity element and indicate a fun, positive approach to healthy living.

Recruitment procedures and challenges

The following approaches were taken for recruiting suitable parent-toddler pairs:

* To encourage self-referrals, flyers were sent to potentially eligible families on the caseloads of two local GP practices, and distributed with the monthly Sure Start newsletter, as well as in local community centres and health centres

* To encourage health professionals to refer eligible families, flyers were sent to local health visiting teams; their meetings were also attended. Families of at-risk toddlers with whom the community nutritionist and health visitor were already working received a personal invitation to attend the programme.

Thirteen families were initially referred. Introductory pre- programme home visits were made to each family to inform them about the sessions and to check that the children met inclusion criteria. However, of the 13 referrals, only three families both met the inclusion criteria and were able to attend on the day and time specified.

The main reasons for poor recruitment of suitable families are as follows:

Poor parental perception of child obesity

Research7 has shown that mothers of overweight preschool children are not worried about their children’s weight, and in one study described them as ‘solid’. Another study of more than 600 mothers with children aged between 23 and 60 months found that over three- quarters failed to perceive their overweight child as overweight. This misperception was more common among less-educated mothers8.

Accordingly, toddler overweight did not seem to be an issue or priority for many of the parents approached for the Sure Start intervention. Anecdotal evidence suggests that parents of young children who appear overweight may attribute this at toddler age to ‘puppy fat’ and as a sign of a strong, healthy child with a good appetite.

Commitment Issues

Some families who met the inclusion criteria and were interested in attending were unable to commit to an 11-week programme for a variety of personal reasons.

Inappropriate referrals

Inappropriate referrals were received from:

* Parents (self-referrals) who were keen to attend but whose children did not meet the inclusion criteria for age and/or BMI

* Health visitors or nursery nurses who, in many cases, inappropriately referred children without calculating their BMI.

Limited outreach resources

Community practitioners often report that promoting and recruiting for such a programme is a time-consuming process. Certainly, many Sure Start colleagues have confirmed similar challenges in running community groups. The programme coordinators had little capacity alongside other work commitments to undertake the level of outreach required to recruit eligible families. In addition, many of the health visitors were so busy in their daily practice that they were unable to dedicate extra time for recruitment.

Programme attendance

Commitment difficulties were experienced even among the three eligible families who were successfully recruited. So, in order not to waste resources, the co-ordinators decided that the programme should be opened up as a drop-in to any parents with toddlers who expressed an interest, even if they did not meet the recriutment criteria. Following this, the programme reached a total of nine families, of which five attended regularly.

Throughout the 11 weeks, a number of issues were identified as contributing to poor regular weekly attendance and retention, most relating to the nature of the toddler age group. For example:

* Unpredictable nap times;

* Frequent child sickness or doctor/ hospital appointments;

* Difficulties due to poor weather conditions; and

* General lack of routine for toddlers, as compared to schoolchildren who tend to have more structure to their day.

Programme outline for parent/carer workshops

The post-exercise workshops for parents and carers were designed to be informal and interactive, where possible, as well as educational. Parents were encouraged to problem-solve and share ideas, as well as develop their own strategies for healthier lifestyle changes. Flip charts were available to help facilitate the discussions. Topics covered each week were as follows: Week 1: Introduction and explanation of the programme

In this session, parents’ expectations were identified and the programme timetable distributed. Lively discussion was held on the causes of obesity among young children.

Week 2: Why does size matter?

This session asked: what is overweight and obesity; how are they measured; what are the health consequences? An optional BMImeasuring activity engaged parents well. Children’s BMI centile charts were introduced and these also stimulated parental interest.

Week 3: What Is a healthy diet?

This session introduced the different food groups, the Balance of Good Health plate model and the particular needs of the young child. Delivered largely as a theory session, this period would have benefited from allowing parents more time to reflect on their own family’s diet in relation to healthy eating guidelines.

Week 4: Getting more active

This session looked at the importance of physical activity for children, current recommendations, and barriers to, activity. The parents/carers found it difficult to discuss ways to increase activity for toddlers, as they believed their children were already very active.

Week 5: Setting goals

This session introduced SMART goals (Specific, Measurable, Achievable, Realistic and Time-limited), and parents/carers were encouraged to set a family food and/or activity goal to work on over the forthcoming week. The parents/carers enjoyed the opportunity to reflect on where and how their family could start to make changes.

Week 6: Reading food labels

This session reviewed the previous week’s goal-setting task before looking at food labels and child food promotions. Food packets were provided to allow the parents to practise reading labels and compare products. This interactive session stimulated much discussion and interest. It was suggested that more baby and child food should be included in future sessions.

Week 7: Helping fussy eaters

This session emphasised the fact that fussy eating is a normal part of a child’s development, and discussed key strategies for avoiding food fads. The parents/carers appreciated the opportunity to discuss ideas and share tips.

Week 8: Managing mealtimes and behaviour

This session looked at strategies for general behaviour management, including setting boundaries, routines and consistency, and at strategies for managing mealtime behaviour, such as removing distractions and praising good eating. However, there was some overlap and both facilitators and participants suggested that weeks seven and eight could have been combined.

Week 9: Keeping good habits going

This session reflected on the goals parents/ carers had set throughout the programme, and on lifestyle changes made and planned.

Week 10: Moving on

This session continued discussions on lifestyle changes and how the programme could be improved for future groups.

Week 11: Evaluation, certificates and celebration

Parents/carers requested party-style foods for this final session, and healthy snacks such as pitta bread fingers, houmous and vegetable sticks were provided. Certificates of attendance were also awarded to the children. An informal evaluation discussion gave the parents/carers a final opportunity to give their feedback on positive and negative aspects of the programme.

Programme evaluation

Qualitative evaluation feedback from the programme co-ordinators and participants, and suggested recommendations for future interventions, are summarised in Table 1.

Discussion

It has been difficult to measure the true impact of Fighting Fit Tots on weight status due to the limited evaluation methods used. However, a number of parents/carers reported that their children showed an increased willingness to drink water and try new foods at home, especially fruit and vegetables, and to spend less time in front of the television; the children also showed increased levels of confidence.

It is recognised that verbal evaluation methods, as used here, could lead to bias in parent responses. Consideration should, in future, be given to incorporating structured, confidential evaluation methods and also to measuring short-term changes in behaviour among toddlers and families. For example, researchers should look at physical activity levels, sedentary behaviour, fruit and vegetable intake, dietary variety in general, fluid intake, incidence of fussy eating, and parental feeding styles.

When developing early years’ obesity interventions it has been suggested that, rather than categorising toddlers as overweight and recruiting on this basis, practitioners should take a public health approach to preventing childhood obesity by working with all families promote healthy eating and physical activity6.

Having said this, health professionals should also be alerted to toddlers in their community who may have poor dietary habits, or the fact that one or more parents are overweight; these children should then be referred for any locally available healthy lifestyle interventions.

Community practitioners interested in setting up projects similar to the Fighting Fit Tots programme should consider the following issues:

* Either a closed group with inclusion criteria, or a public health approach open to all (preferable)

* Availability and accessibility of suitable venue

* Maximum number of participants that the venue and facilitators can safely manage

* Provision of healthy snack-time refreshments

* Availability of practitioners, including: project co- ordinator, children’s fitness instructor (or equivalent activity), discussion group facilitator(s), creche workers, outreach workers for recruitment

* Availability of funding resources

* Administrative support

* Partnership working (for example, with local Sure Start children’s centres or other early years settings)

* Structured evaluation methods and behaviour change measurement tools

* Sensitive publicity – during the programme it became apparent that the physical activity component was largely responsible for drawing parents in. Future groups may therefore find it helpful to use the parent-toddler physical activity sessions as the main marketing and recruitment tool.

Conclusion

The main lesson learned from Fighting Fit Tots centred around the recruitment of participants and the use of inclusion criteria which, other than age, may be best avoided for a community-based programme of this type. There remains a challenge for community practitioners in recruiting to such interventions using weight-related criteria, due to poor parental awareness of toddler overweight. Practitioners are, therefore, advised to adopt a public health approach to obesity prevention by offering healthy lifestyle programmes as fun parent- toddler groups to all families with young children, incorporating the essential elements of physical activity, dietary education and behaviour modification. At-risk children and families should, of course, be specifically targeted for intervention where outreach capacity allows.

Fighting Fit Tots will continue to run in Lambeth, south London, promoted as a parent-toddler healthy lifestyle programme and funded by the Sure Start children’s centre. As before, the weekly physical activity sessions will be followed by a healthy snack break of either fresh fruit or raw vegetable sticks (with pitta fingers, breadsticks and healthy dips). Following this, children will be cared for in a creche room while parents have the opportunity to engage in an educational and interactive group workshop. These discussions will make more use of interactive tools such as quizzes (where appropriate), and will be based on the original programme outline as described above.

Additionally, MEND can learn from the experience of Fighting Fit Tots to successfully adapt the MEND Programme for the early years. Currently in development, it is anticipated that MEND for the early years (Mini-MEND) will be available to communities across the UK from May 2008.

To conclude, running the feasibility pilot programme within a Sure Start setting was a promising experience, and health professionals should be encouraged to implement similar family- based obesity prevention initiatives targeting the ‘neglected’ (as far as overweight is concerned) toddler group.

For more information contact: Julia Wolman RPHNutr.

E nutrition@juliawolman.co.uk;

T: 07974 767026.

Research has shown that mothers of overweight pre-school children are not worried about their children’s weight, and in one study described them as ‘solid’. Another study of more than 600 mothers with children aged 23-60 months found that over three-quarters failed to perceive their overweight child as overweight.

References

1. Miller J, Rosenbloom A, Silverstein J. Childhood obesity. J Clin Endocrinol Metab 2004; 89(9): 4211-8.

2. Health Survey for England 2004. Updating of trend tables to include childhood obesity data, 2005.

3. Lobstein T, Baur L, Uauy R. Obesity in children and young people: a crisis in public health. Obes Rev 2004; 5 Suppl 1:4-104.

4. Whitaker RC, Wright JA, Pepe MS, Seidel KD, Dietz WH. Predicting obesity in young adulthood from childhood and parental obesity. N Engl J Med 1997; 337(13): 869-73.

5. Sacher PM, Chadwick P, Wells TC, Williams IE, Cole TJ, Lawson MS. Assessing the acceptability and feasibility of the MEND Programme in a small group of obese 7-11 -year-old children. I Hum Nutr Diet 2005; 18(1): 3-5.

6. Sacher PM, Chqadwick P, Kolotourou M, Cole TJ, Lawson MS, Singhal A. The MEND RCT: Effectiveness on health outcomes in obese children. Int I Obesity, 31: S1

7. Jain A, Sherman SN, Chamberlin LA, Carter Y, Powers SW, Whitaker RC. Why don’t low-income mothers worry about their preschoolers being overweight? Pediatrics 2001; 107(5): 1138-46.

8. Baughcum AE, Chamberlin LA, Deeks CM, Powers SW, Whitaker RC. Maternal perceptions of overweight preschool children. Pediatrics 2000; 106(6): 1380-6.

Julia Wolman BSc (Hons), MSc, public health nutritionist Lambeth PCT

Eleanor SteHy BSc (Hons) MSc, health visitor

Lambeth PCT

Merla Kokrtourou BSc MSc, nutrition research

assistant for the MEND Study, MRC Childhood

Nutrition Research Centre, Institute of Child Health,

University

College London

Dr Margaret Lawson PhD MSc, dietitian, senior

research fellow, MRC Childhood Nutrition Research

Centre, Institute of Child Health, University College

London

Paul Saciwr BSc (Med) Hons, senior research fellow,

MRC Childhood Nutrition Research Centre, Institute of

Child Health, University College L ondon

Copyright TG Scott & Son Ltd. Jan 2008

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