Addressing Childhood Obesity: Literature Review

Introduction

This quantitative quasi-experimental DPI project is aimed at examining the effect of education about physical activity received by parents on obesity levels observed in school-aged children residing in the Southeast region of the United States. Therefore, this chapter provides a review of the existing literature on a variety of interventions and approaches that are currently applied by parents and professionals to address the issue of childhood obesity. The chapter includes the background information on the problem of obesity in school-aged children and parental involvement, the section on theoretical foundations guiding this research, and the literature review section. This major section is divided into subsections discussing key themes identified in the literature and related to the project variables: childhood obesity, parental involvement, parents’ awareness, interventions, ethnic and cultural diversity, community and family involvement.

The recently published literature on the problem of obesity in school-aged children as well as interventions and programs for parents has been reviewed and analyzed for this study. The following databases and resources were used to search for, survey, and retrieve appropriate articles from peer-reviewed journals: Google Scholar, PubMed, ScienceDirect, EBSCOhost, and CINAHL database. The keywords used during the search included different combinations of the following words: “school-aged,” “children,” “obesity,” “parents,” “parental,” “family,” “involvement,” “intervention,” “physical activity,” “prevalence,” “education,” “community,” “comorbidity,” “diversity,” “ethnic,” and “cultural.” Consequently, 212 articles on the topic of this research were retrieved, and their abstracts were analyzed with reference to the inclusion criteria: the publication date, the relevance to the topic, and the type of research. Fifty-one studies that were published between 2015 and 2019 have been selected for further analysis in the context of this research. The information found in the articles has allowed for determining the major themes related to the problem and topic of this research that is discussed in separate subsections in this chapter.

The problem of improving the physical activity of children living in the United States to prevent obesity has been discussed since the 1950s. In those years, researchers compared the physical fitness of children in the US and European countries for the first time. Researchers’ concerns were later supported by evidence indicating the development of the obesity epidemic among school-aged Americans (Davis, Wojcik, & DeWaele, 2016). In 2012, it was reported that the rate of childhood obesity almost quadrupled (up to 21%) in comparison to the data for the previous 30 years (Davis et al., 2016). Thus, the current rate of obesity among children in the United States is about 20% (Hales, Carroll, Fryar, & Ogden, 2017). According to Fradkin, Wallander, Elliott, Cuccaro, and Schuster (2016), Hispanic and African American children are twice as likely to suffer from obesity in comparison to White youth. This tendency can be associated with socioeconomic and cultural factors.

Numerous interventions to address the problem of obesity among children were found in the articles on the topic. However, despite the active discussion of family-based interventions, there are still gaps in research related to understanding their significance to decrease body mass index (BMI) in children of different ethnic and socio-cultural backgrounds. Researchers have concentrated on examining family-based interventions and programs exclusively for parents (Knol et al., 2016; Nyberg et al., 2015). Nevertheless, there is still a lack of evidence on how they predict changes in children’s BMI and physical activity. Thus, the effectiveness of specific interventions to improve the physical activity of children with obesity still requires further examination.

Theoretical Foundations

Social cognitive theory (SCT) is the major theoretical model that guides this research. According to the key assumptions and principles of this theory, individuals’ behavior is formed by certain interactions between specific behavioral, social or environmental, cognitive, and personal factors. This theory was introduced by Albert Bandura in 1986 as a result of developing his social learning theory that had been formulated in the 1970s. Bandura (1986) stated that an individual’s behavior is based on the impact of his or her environment and on a personal ability to regulate this behavior. This principle was described in detail in Bandura’s Social Foundations of Thought and Action: A Social Cognitive Theory that is currently used as a seminal work to explain SCT. Thus, the author of the theory changed the focus from observational learning to cognitive processes that occur during this learning and directly affect individuals’ behavior.

In this book, the psychologist described the critical aspects of his theory discussing the origin of individuals’ behavior from a unique social-cognitive perspective. Bandura (1986) built his theory on such important components as behavioral capability or the understanding and confidence, self-efficacy, outcomes, expectancies or values, observational learning or modeling, self-control, and incentives. The author also explained how the principles of his theory could be used to analyze personal changes depending on the social change or alterations in the environment.

SCT is actively applied to develop physical activity programs and nutrition recommendations for people suffering from obesity because the theory guides and support the designing of interventions oriented toward changing environmental factors and behaviors. From this perspective, the clinical question formulated for this study directly aligns with the assumptions and ideas associated with SCT. The reason is that the question asks how obesity in children can be affected as a result of receiving education regarding physical activity by their parents. In the context of this research, it is expected to observe how environmental factors, such as changes in parents’ awareness, beliefs, and behaviors, can contribute to changes in children’s behavior regarding their physical activity. Thus, SCT is appropriate to explain how the physical activity of children with obesity as one of the variables can change depending on such a factor as their parents’ education on this aspect.

By referring to the key concepts of the theory, it is possible to understand in much detail how SCT guides this research. The behavioral capability of an individual is associated with understanding why and how to change a certain behavior and why to focus on increasing physical activity in the context of the study. Self-efficacy is related to individuals’ confidence in their will and ability to change the situation (Knol et al., 2016). A person needs to be motivated to change depending on their expectations, values, and benefits of altering the behavior. All these changes are the result of observational learning or references to the example of parents, in this case, self-control stimulated by educated parents, and provided reinforcements (Bagherniya et al., 2017). According to Lee et al. (2017), changes in parents’ behaviors and environments can directly influence children’s attitudes to their usual diet and lifestyle. This principle also works for the case of increasing physical activity as changes in parents’ behaviors, habits, and discussions can shape children’s expectations and behaviors.

While applying SCT to this research, it is possible to state that parents will be perceived as role models for children to influence their observational learning. Furthermore, they change the environment in households to stimulate physical activity. According to Bagherniya et al. (2017), changes in home environments are extremely significant for children to alter their behavior and address obesity. It is important to create an atmosphere where children will be not only motivated to increase their physical activity but also supported by parents whose task is to stimulate children’s self-regulation (Knol et al., 2016). When receiving the knowledge and education related to their children’s status and interventions to address obesity, parents become key actors in shaping the environment around youth to achieve changes in children’s physical activity and health.

Review of the Literature

In this section, the review of the literature on such an independent variable as parents’ involvement in an educational intervention on physical activity is presented. Additionally, the literature on dependent variables, such as children’s obesity and physical activity, has also been reviewed, and its analysis is presented in the chapter. Moreover, studies involving the use of self-reported body weight and height (SRBW and SRBH) measurements, as well as the Physical Activity Questionnaire for Children (PAQ-C), are also discussed to support their selection for the project. Thus, the topics related to the variables and the factors that can influence the study results, including family involvement and ethnicity among others, are also reviewed in this chapter.

Childhood obesity

The review of the articles on the topic has contributed to defining the notion of childhood obesity as the dependent variable used in this research. That is the reason for examining researchers’ findings on childhood obesity in the United States in terms of prevalence, risk factors with a focus on ethnicity, and comorbidity. There are many recent studies aimed at determining specific social, genetic, and behavioral factors that trigger the development of childhood obesity, and nine relevant studies have been reviewed in relation to this topic.

Prevalence

The prevalence of obesity among children in the US varies by different factors, including ethnicity and parents’ income among others, and its trends have changed over time. In their study on these trends, Ogden et al. (2016) focused on examining and comparing obesity tendencies in American children and adolescents for 1988-1994 and 2013-2014. The researchers used the data of National Health and Nutrition Examination Surveys (NHANES) for individuals aged 2-19 years and analyzed the measurements for 40,780 children. The researchers found out that obesity prevalence in 2011-2014 was 17%, and it increased for children of all age groups while comparing the results with the data for 1988-1994. After 2004, the prevalence began to decrease for children aged 2-5 years and remained stable for children aged 6-11 years, but it was still higher than the prevalence observed in 1988-1994.

The latest data available regarding the prevalence of obesity in children in the US is related to the period of 1999-2016. Skinner, Ravanbakht, Skelton, Perrin, and Armstrong (2018) examined and analyzed the updated information in their article. The researchers referred to the NHANES data and measured it using statistical analysis and determining p values. It was found out that African American and Hispanic children had significantly higher overweight and obesity rates in comparison to White and Asian American children, and obesity prevalence increased for 2-5-year-old children during 2015-2016. It is possible to state that these data added to the findings provided by Ogden et al. (2016).

Such factors as income and the education level of household heads were also discussed in the literature in the context of obesity prevalence. Ogden et al. (2018) were interested in finding the relationship between income, education level, and obesity. They referred to the NHANES data for 2011–2014 and found out that the highest prevalence (19.9%) was observed among children belonging to the middle-income group. These data allow for further examining this relationship in order to determine trends.

Ethnicity

The ethnicity of children with obesity has been determined in the literature as a risk factor indicating trends in obesity prevalence. In their quantitative study, Guerrero et al. (2016) examined changes in BMI in children belonging to different ethnic groups. By applying statistical analysis, the researchers found out that Latino and African-American children had higher BMI scores in comparison to White children. Davis et al. (2016) also focused on comparing the levels of obesity and physical activity in students depending on their gender and race. Referring to the sample including 413 students, the researchers found out that White students demonstrated better results regarding physical activity and BMI in comparison to students of other races.

The mentioned findings are credible based on the applied methodology and sample sizes, and they are supported by other studies on the topic. Still, according to Fradkin et al.’s (2016) community cohort study involving 4824 children, lower-intensity physical activity contributed to decreasing obesity rates mostly in White and Hispanic male participants. There was no such relationship between females and representatives of African Americans. Furthermore, Kee et al. (2017) used SRBW and SRBH for studying changes in weight in diverse school-aged children and accentuated the effectiveness and accuracy of the measurement. Olfert et al. (2018) also studied the problem of childhood obesity with reference to the use of SRBW and SRBH as measurements to determine children’s status. They noted that self-measurement reports were rather accurate, and they were used for determining weight in representatives of different ethnic groups.

Comorbidity

Obesity is a complex health condition that usually leads to the development of comorbid diseases. According to the qualitative study by Sahoo et al. (2015), overweight and obesity in children are often associated with such comorbidities as cardiovascular disease, hepatic and renal disorders, and diabetes. The environment and lifestyle choices influence the development of these comorbid conditions. According to Pandita et al. (2016), obesity has many comorbidities leading to the discussion of this condition as the fifth risk factor for mortality among other ones identified globally. Therefore, the researchers accentuated the necessity of developing novel interventions to prevent obesity in children as a vulnerable category. Peters et al. (2016) also conducted a quasi-experimental study to determine how communities can influence children’s weight status. The researchers found that, in 14 rural communities, the low rate of obesity among children was associated with active community efforts and interventions oriented toward addressing the issue.

Childhood obesity is discussed and analyzed in the existing literature with reference to its prevalence, the factor of ethnicity, and comorbidities. Although some researchers found decreases in obesity prevalence typical of recent years, others stated that it remained stable or even increased (Ogden et al., 2016; Skinner et al., 2018). Therefore, further analysis of existing and updated statistics is required. The prevalence of obesity is higher among Hispanics and African Americans, and this aspect influences the choice of the population for this study. Researchers also provided credible evidence to accentuate the risks associated with obesity because of its comorbidities.

Parental involvement

Another theme that is actively discussed in the literature on the efficiency of obesity prevention interventions for parents is parental involvement. Studying the use of different interventions to promote children’s health, researchers found out that parental involvement in programs was a critical factor in improving outcomes for children (Clarke et al., 2015; Parrino et al., 2016). Findings from several studies allowed for determining such subthemes as the involvement of parents in implementing health interventions, the provision of parents’ support, and parents’ knowledge and education on obesity.

Involvement of parents

Parent involvement was studied in the context of parents’ activities to contribute to changing children’s lifestyles and behavior. According to Braden, Strong, Crow, and Boutelle’s (2015) quantitative randomized study, family-based interventions to address childhood obesity significantly depend on parental involvement. Referring to the participants from San Diego and Minneapolis, the researchers found out that parents changed agents in their families. Parents’ focus on improving their own weight influenced the weight of children (Braden et al., 2015). Still, this effect was not proved for changes in children’s physical activity depending on the example of their parents.

The effectiveness of parent involvement was accentuated in the reviewed studies, but some limitations were also listed. In their qualitative study based on the use of focus groups, Clarke et al. (2015) explored the obesity prevention intervention applied to children in the UK and found out that parental involvement influenced its success. Thus, parents recognized their important role in forming children’s behavioral changes. Additionally, according to Kim, Park, Park, Lee, and Ham’s (2016) randomized controlled trial involving 42 parents of children with obesity that was aimed at evaluating a parent involvement intervention, children’s behavior can change significantly. However, the researchers found positive relationships only between parental involvement and changes in children’s diets, but there was no relationship between the intervention and changes in BMI (Kim et al., 2016). The results of this research can be limited by a sample size which is rather small for this type of inquiry. These studies’ findings indicate that parent involvement directly influences changes in children’s behaviors, but not all of them, and the effect can depend on the intervention.

Parents’ support for children

Conclusions about the role of parent involvement found in the reviewed literature were also related to the theme of support and the importance of being supportive for parents. Morris, Skouteris, Edwards, and Rutherford (2015) conducted a systematic review of studies on obesity prevention interventions. The researchers stated that parental engagement, involvement, and support in the context of programs addressing obesity were effective to change children’s BMI. Parrino et al. (2016) performed a quantitative study involving 1521 Sicilian children for the purpose of determining the role of parental factors in the development of obesity in children. They stated that mothers’ obesity and their low education and support levels were correlated with higher risks of children’s obesity, and these findings are statically significant. In their qualitative study, Zhao, Li, and Rukavina (2017) also focused on exploring how parents could support their children with obesity. It was found out that being supportive, teaching self-acceptance, and providing advice were important aspects to help children with obesity in problematic situations at school, including teasing. Thus, studies show that parents’ supportive behaviors are critical in helping children cope with their obesity problem.

Parents’ knowledge and education regarding children’s obesity

It was indicated in the literature that parents’ knowledge regarding risks of obesity, a healthy lifestyle, nutrition, and exercising could be improved with the help of education and was correlated with children’s obesity levels. Yavuz, Van Ijzendoorn, Mesman, and Van der Veek (2015) prepared the meta-analysis of studies on obesity intervention programs. The researchers conducted meta-regression analyses and concluded with reference to 76 studies that interventions involving parents were most effective to address children’s obesity after parents had improved their and children’s knowledge of the condition.

Parent involvement can have positive effects on children with obesity if parents are educated regarding the issue and correctly recognize their children’s status. In their study on parental misclassification of children’s weight status, Cullinan and Cawley (2017) examined the importance of parental education in this area. It was found out that better-educated parents, as well as parents without problems with their own weight, discussed their children’s weight status rather accurately. Thus, parents usually tend to perceive their children’s weight as normal rather than to report overweight or obesity. Zacarías, Shamah-Levy, Elton-Puente, Garbus, and García (2019) conducted their study on interventions for children having obesity with reference to the sample of mothers of such children from Mexico. The researchers showed that the intervention oriented toward improving mothers’ knowledge and changing their behavior positively affected children’s weight status. The research indicates that parents need to improve their knowledge regarding weight problems to help their children.

The topic of parental involvement includes the issue of involvement itself, parents’ support for children, and parents’ knowledge and education that are critical to influencing youth’s behaviors referring to parents as role models. However, researchers’ conclusions regarding the effectiveness of parental involvement are different. Involvement and support positively affect behavioral changes in children (Clarke et al., 2015), but there are no significant trends regarding changes in BMI and physical activity (Braden et al., 2015; Kim et al., 2016). Still, Morris et al. (2015) found a positive correlation between parental engagement and BMI. However, researchers agree that parental involvement and their improved knowledge regarding obesity have significant effects on changes in children’s behaviors, lifestyles, and weight status (Cullinan & Cawley, 2017; Yavuz et al., 2015). This factor is important to explain why to use education sessions and interventions for parents to address their children’s obesity.

Parents’ awareness

In addition to the theme of parental involvement, the literature also provided data on the importance of parents’ awareness of the existence of overweight and obesity in their children. Researchers identified such subthemes related to the question as parents’ perceptions of obesity, responsibility, and perceptions of health and physical activity (Davidson & Vidgen, 2017; Liu et al., 2017; Wright et al., 2016). This issue is important to be analyzed with reference to evidence because parents’ awareness is a significant aspect to influence the effectiveness of educational interventions for parents.

Parents’ perceptions of obesity in children

The problem is that many parents of children with weight problems are not aware of this fact. Wright et al. (2016) assessed parents’ perceptions regarding obesity with the help of a survey in the United States. The researchers found out that some parents of children with overweight and obesity problems did not perceive them as having these problems. Still, these parents recognized the risks of developing health problems for these children (Wright et al., 2016). This study refers to the sample of only 502 parents, and more research is required in this area.

Parents’ perceptions of their children’s weight status can be impacted by different factors. Queally et al. (2018) were interested in studying whether mothers appropriately recognized their children’s weight. While referring to the data for the context of Ireland, the researchers stated that mothers frequently could not recognize the weight of their children accurately. Their perceptions were influenced by such factors as a child’s gender and age, mothers’ education and knowledge, income, and the place of living (urban or rural areas) (Queally et al., 2018). These findings can be supported by conclusions made by Love, Laws, Litterbach, and Campbell (2018), who studied parental engagement in an obesity prevention program for infants with the help of the qualitative methodology. The researchers found out that those parents who had less knowledge and experience were more involved in the program than parents with higher self-efficacy (Love et al., 2018). Therefore, parents’ perceptions of children’s weight status and associated knowledge can influence their engagement in interventions and outcomes, but more research is required to study this aspect.

Parents’ responsibility

The responsibility of parents related to their activities in order to address children’s problem of obesity is actively discussed in the existing literature on the topic. As a result of analyzing survey data on parents’ behaviors and the problem of childhood obesity, Wolfson, Gollust, Niederdepper, and Barry (2015) found that parents focused on the concepts of blame and responsibility. Parents with higher responsibility levels were inclined to more actively support school and community policies on obesity prevention.

It is important to pay attention to two more studies related to the topic of responsibility. Lauricella, Wartella, and Rideout (2015) performed a quantitative linear regression analysis to measure screen time for children with its reference to obesity and other adverse effects. Referring to the results related to a large sample of 2300 parents, the researchers found out that parents’ own screen time was correlated with their children’s screen time. The strength of this study is in using a large sample, and the findings can explain the importance of parents’ responsibility regarding acting as positive role models for their children. Moreover, Davidson and Vidgen (2017) conducted a qualitative study aimed at investigating parents’ motivation to be enrolled in healthy lifestyle programs. After analyzing interviews, the researchers found out that the key factor in becoming enrolled in the program was parents’ awareness of children’s weight status and their acceptance of their personal responsibility. From this perspective, parents’ awareness is directly related to the issue of parents’ responsibility, the higher levels of which can potentially lead to positive changes in children’s lifestyles.

Parents’ perceptions of children’s health and physical activity

Parents’ activities to prevent obesity in children also depend on perceptions of their children’s health and the role of physical activity in achieving success. Columna, Rocco Dillon, Norris, Dolphin, and McCabe (2017) conducted a qualitative study with 10 parents, whose perceptions regarding children’s physical activity were examined in detail. It was found that parents were not inclined to motivate their children to improve their physical activity because of certain health conditions perceived as barriers. The weakness of this study to support the current research is associated with its qualitative methodology and the primary reference to children with visual impairments.

Other researchers focused on examining parents’ visions of children’s physical activity in other cultural contexts. Thus, Liu et al. (2017) conducted a quantitative study involving 81,857 school-aged Chinese children to determine the relationship between parental support and physical activity levels. They revealed that parents’ positive perceptions of sport, their encouragement, and support were associated with children’s higher participation in physical activities. Still, McGee, Richardson, Johnson, and Johnson (2017) chose an opposite perspective in their qualitative study involving seventy African-American children. The researchers found out that these young individuals recognized healthy patterns and unhealthy behaviors leading to obesity referring to their parents’ teaching. If parents have developed knowledge regarding healthy lifestyles and their perceptions of physical activity are positive, they influence children’s healthy behaviors and prevent obesity.

The awareness of parents regarding youth obesity is reflected in their perceptions of possible weight problems in their children, their responsibility to create appropriate environments to avoid obesity, and their perceptions of physical activity. The findings of both quantitative and qualitative studies indicated that parents often could not perceive their children’s weight accurately (Queally et al., 2018; Wright et al., 2016). Despite being aware of their responsibility to promote children’s health, parents also made different decisions regarding the promotion of children’s physical activity depending on perceptions and biases (Columna et al., 2017; Davidson & Vidgen, 2017). Therefore, parents’ awareness of their children’s health is important to be examined to understand how they will respond to children’s obesity and what biases or areas need to be addressed to make interventions work.

Interventions to address childhood obesity

The discussion of interventions oriented toward preventing and addressing obesity in children represents another large topic widely covered in the literature on the problem. The authors of the reviewed studies were interested in examining types of interventions, children’s physical activity in relation to BMI, and technology-based interventions (Cochran & Baus, 2015; Gicevic et al., 2016; Nyberg et al., 2015). The theme of interventions for parents is directly related to the problem studied in the current research. Thus, it is important to analyze other researchers’ conclusions regarding the most effective programs that can be used in family-based environments and interventions involving only parents to educate them regarding childhood obesity.

Types of interventions

The majority of the reviewed studies on interventions to prevent obesity were oriented toward assessing their effectiveness. Gicevic et al. (2016) conducted a quantitative content analysis to discuss the recent research on childhood obesity and interventions. They found referring to 667 studies that most studies were quantitative (80%), and they mostly addressed dietary changes (57%) in contrast to physical activity (23%) (Gicevic et al., 2016). Lee et al. (2015) measured the effectiveness of interventions to increase the physical activity level in children with the help of the Physical Activity Questionnaire for Children (PAQ-C) and supported its validity, consistency, and accuracy. In addition, Weihrauch-Blüher et al. (2018) reviewed the literature on preventing obesity in childhood and found out that the most effective programs and interventions were school-based ones. These programs work as behavior-oriented prevention, but these interventions cannot demonstrate positive long-term effects on children at risk of obesity. Therefore, there are gaps in research on interventions to overcome childhood obesity that need to be addressed with the help of the current study.

Children’s physical activity

Another subtheme discussed in the literature on interventions is related to assessing their effectiveness to improve the physical activity of children with obesity. Nyberg et al. (2015) conducted a cluster-randomized controlled trial in Sweden to measure the effectiveness of a program based on the principle of parental support to prevent obesity. It is important to note that the findings revealed that the intervention had no positive effects on children’s obesity and physical activity levels. On the contrary, Knol et al. (2016) tested Home Sweet Home, the obesity prevention program based on home environments. It was found that this program contributed to preventing and addressing obesity through decreasing hours spent on sedentary behaviors, reducing calorie intake, and improving physical activity. Bagherniya et al. (2017) conducted a systematic review to assess the effectiveness of different obesity intervention programs with reference to the principles of SCT. The reduced BMI was the outcome of different SCT-based interventions, but their role in improving children’s physical activity and lifestyle was found to be insignificant. These findings point to the necessity of evaluating the role of other interventions in improving children’s health and activity.

Technology-based interventions

A large amount of literature is dedicated to discussing modern technology-based interventions to address obesity in children. Cochran and Baus (2015) studied the interventions for children with obesity that were based on electronic health records. They found out that the information collected with the help of these records could be helpful for healthcare providers working with these patients. Moreover, Avis et al. (2015) conducted a multi-method study to develop an intervention oriented toward increasing parents’ motivation regarding the adoption of a healthy lifestyle to address obesity. The authors stated that parents could successfully use advanced applications to promote healthy lifestyle choices among their children. Lee et al. (2017) also examined the use of mHealth tools as interventions for addressing obesity in children with intellectual disabilities. The researchers invited 115 participants and used regression models to find that the tool had a positive impact on the knowledge of students regarding their body weight and BMI (Lee et al., 2017). Thus, the findings can be discussed as valid and reliable. They support the effectiveness of using advanced technologies and modern interventions to improve children’s health status and prevent obesity.

The literature on interventions to address childhood obesity covers such large themes as types of effective interventions to use by parents and other agents and the relationship between using interventions and changes in physical activity. One more theme is the modern trend of using technology-based interventions to promote health. The review of nine articles has indicated that there is no strong evidence of a positive relationship between applying interventions and changing children’s physical activity. Therefore, more research is needed in this area with a focus on this project’s contribution.

Ethnic and cultural diversity

While studying the effectiveness of different types of interventions in preventing obesity in children with a focus on family-based programs and parental involvement, researchers also referred to the aspects of culture and ethnicity. According to Davis et al. (2016), representatives of some races are more predisposed to obesity than other individuals. Moreover, some ethnic and cultural groups less actively adapt interventions and changes than others (Ordway et al., 2018). Therefore, this topic is important to be identified for the discussion in this literature review because outcomes of parents’ education and interventions for children tend to depend on specific ethnic and cultural backgrounds and contexts.

Ethnic and racial disparities

BMI is discussed to be usually higher in Hispanics and African Americans than in Whites. Zilanawala et al. (2015) studied racial disparities regarding risks of obesity in children with a focus on 5-year-old participants from the UK and the US. The researchers stated that race and cultural factors played an important role to influence BMI in the UK-based population. However, in the US population, there were no reported ethnic disparities regarding obesity levels. Opposite findings were reported by Davis et al. (2016) who identified better results regarding BMI and physical activity in White students in comparison to children of other races. Guerrero et al. (2016) also examined changes in BMI depending on race and found out that Latino and African-American children had higher BMI levels. Thus, more researchers tend to agree that race plays an important role in determining weight status.

Obesity in Hispanic children

Many studies are primarily focused on examining the obesity issue in Hispanic children. Falbe, Cadiz, Tantoco, Thompson, and Madsen (2015) were interested in examining interventions oriented specifically toward Hispanic children with obesity. As a result of their randomized controlled trial, the researchers noted that the Active and Healthy Families intervention designed for the Latino population had positive effects on decreasing BMI in children. Hatfield, Chomitz, Chui, Sacheck, and Economos (2015) studied changes in physical activity in low-income Hispanic children with obesity. The researchers conducted a quantitative study involving 93 children and found out with the help of regression analysis that only age and gender could predict individuals’ physical activity results. Furthermore, Fradkin et al. (2016) noted that physical activity could contribute to decreasing obesity rates in Hispanic males. Therefore, the findings in these studies on obesity in Hispanic children require further examination and support because of their ambiguity.

Cultural diversity

Researchers also focused on the cultural factor as critical to influencing the success of interventions. According to Mech, Hooley, Skouteris, and Williams’s (2016) systematic review on the role of external factors such as socio-economic status on childhood obesity, parents’ BMI, ethnicity, culture, TV time influence children’s weight. Referring to 30 studies, the researchers found that interventions should be culturally and ethnically oriented in order to help children from low-income and diverse families cope with obesity. In their systematic review, Lofton, Julion, McNaughton, Bergren, and Keim (2016) examined obesity rates among Africa American children and supported conclusions by Mech et al. (2016). They found that specific culturally adapted interventions to address obesity had positive outcomes for the youth. Ordway et al. (2018) also developed a study examining obesity risks for children of Hispanic and low-income backgrounds. Using the data for a randomized controlled trial, the researchers found that a home-visiting intervention was effective to prevent obesity in children aged 0-2 years. Thus, cultural environments, in which children are brought up, tend to influence their weight status.

The topic of ethnic and cultural diversity was widely discussed in the literature on childhood obesity. The reason is that some races and ethnicities are viewed as more predisposed to obesity than others (Guerrero et al., 2016). In addition, racially and culturally oriented interventions have better effects on youth, as was reported by researchers (Mech et al., 2016; Ordway et al., 2018). The focus on Hispanics is important for this project involving parents of children residing in the Southeast region of the US where Hispanics represent a large portion of the population. However, there is a lack of evidence presented in the existing literature regarding the effectiveness of educational interventions for parents to improve the physical activity of their children and decrease BMI.

Family and community involvement

The topic of family and community involvement in activities oriented toward preventing obesity was also described in the literature. Researchers conducted numerous quantitative and qualitative studies to compare and assess family- and community-based interventions for preventing obesity in children (Muthuri et al., 2016; Wang et al., 2015). This area of knowledge is directly related to the problem studied in this project because of explaining the role of external factors in changing children’s behaviors.

Family-related factors

There are numerous factors related to the family environment that influence childhood obesity, including dietary habits, parents’ lifestyle, and parents’ weight among others. Muthuri et al. (2016) studied the relationship between parental education and weight and children’s obesity and physical activity. The provided evidence is strong as the researchers collected data from 4752 children from 12 countries and stated that parents’ overweight was positively correlated with children’s weight. Parents’ education was associated with the absence of overweight, and there was no positive relationship between education and physical activity in families from developing countries.

Parents’ weight and habits as influential factors were also examined in other studies. According to Xu and Xue’s (2016) review, family factors and environments played an important role in influencing children’s obesity. Lifestyle habits associated with spending more time watching television and using computers result in decreasing children’s physical activity in contrast to the increased intake of calories per day. Moreover, Liu et al. (2018) examined the relationship between parents’ education and income and their children’s weight. Referring to a questionnaire survey with 3670 participants from China, the researchers revealed that the interaction was observed for the education of fathers and their children’s obesity. However, there were no findings to support the interaction between mothers’ education and children’s weight.

Family involvement

The topic of family involvement was discussed in the reviewed articles in relation to family-related factors and environments. According to Braden et al.’s (2015) quantitative study, when parents become involved in changing their weight, children tend to imitate their behavior. Still, following Nyberg et al. (2015), interventions based on family involvement do not always result in positive outcomes for children. Moreover, in their open-label randomized study, Yackobovitch‐Gavan et al. (2018) also focused on evaluating the effectiveness of family-based interventions for preventing obesity in children. By referring to the data on 247 children, the researchers claimed that the most effective family-based interventions should be oriented toward both parents and their children to achieve higher effects and decrease BMI.

Community involvement

Specific community-related factors were also mentioned by researchers as impacting the prevention of childhood obesity. In their review article, Brown, Halvorson, Cohen, Lazorick, and Skelton (2015) analyzed family and community factors that contribute to obesity prevention in children. Influential community factors include socioeconomic status, ethnicity, school programs, access to food, and access to recreation activities. They also stated that the key family factors to focus on are the home nutritional environment, parenting style, parent modeling, weight status, and monitoring.

Other researchers additionally focused on involving schools in addressing the obesity issue. Wang et al. (2015) quantitatively assessed obesity prevention programs for children to determine the most effective ones. They found out that school-based interventions were rather effective to prevent obesity-related problems in children, but interventions applied in other contexts were not researched in detail. In addition, Berge et al. (2016) were interested in studying community factors in relation to the problem of obesity in children. They applied the community-based participatory research approach in order to test interventions. The researchers found out that both parental involvement and the application of community-based programs had positive effects on the prevention of obesity in children.

Despite disagreements in reviewed articles on family and community involvement in obesity prevention, most researchers concluded that family-based interventions are effective to change children’s weight status. Credible findings of quantitative studies with large samples supported the idea that parents’ examples and changes in home environments are key factors to influence children’s obesity. These conclusions explain the focus of the current research on interventions for parents in the form of family-based ones.

Summary

The review of the literature on childhood obesity has allowed for revealing critical topics: obesity and its prevalence in the US, parental involvement, parental awareness, interventions, ethnic and cultural diversity, and family and community involvement. According to the previous research findings, childhood obesity is more typical for Hispanic and African American youth, and this aspect supports the necessity of focusing on the Hispanic population in this study. Cultural backgrounds and parents’ education and income also influence the spread of obesity in children and the effectiveness of applied interventions. Parental involvement in preventing and addressing obesity is an important factor to influences the outcomes of interventions for children with weight problems.

However, there are still gaps in the existing research that need to be addressed with the help of this study. First, there is a lack of literature on the role of cultural and ethnic factors in influencing the effectiveness of interventions involving parents of children with obesity (Cullinan & Cawley, 2017). Second, findings regarding the effectiveness of parent- and family-oriented interventions and the role of parental involvement are rather opposite regarding potential outcomes for children with obesity (Yackobovitch‐Gavan et al., 2018). There is supporting evidence for both the presence and absence of the relationship between interventions and parent involvement and decreased BMI or increased physical activity (Clarke et al., 2015; Morris et al., 2015). Therefore, more research is necessary to cover this gap and examine the effectiveness of interventions involving parents to increase physical activity and decrease obesity in children. The analyzed data allowed for determining the variables to focus on in this study – parental involvement based on interventions and obesity and physical activity – because more research is needed to examine the relationship between them.

The principles of social cognitive theory with a focus on its relevance for this study have been described in the chapter. SCT is selected as a theoretical foundation for this study because it explains how parental involvement and example can influence changes in children’s health-related behaviors (Knol et al., 2016). The literature has also provided support for the selection of a method and a research design appropriate for this study. Thus, quantitative and quasi-experimental studies were also used by Braden et al. (2015) and Peters et al. (2016), and they provided valid findings. In addition, the use of SRBW, SRBH, and PAQ-C for data collection and analysis was supported by Kee et al. (2017) and Lee et al. (2015), who accentuated the credibility and reliability of these tools.

Referring to the reviewed literature, further research is essential to determine what educational programs for parents will have positive outcomes for children with obesity belonging to certain ethnic groups or living in specific areas. The analyzed literature accentuates the necessity of conducting a quantitative study on the topic of applying interventions for parents in order to educate them regarding physical activity to predict changes in their children’s BMI. From this perspective, additional research in this field will contribute to addressing the gaps that were identified in the existing literature regarding the relationship between interventions involving parents and children’s BMI and physical activity. Chapter 3 will present the information on the methodology selected for this study depending on specific methods, designs, and approaches that were used by other researchers and mentioned in this chapter.

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