Childhood Obesity Interventions: Literature Review

Educational interventions for parents aimed at increasing the physical activity of their school-aged children are of key importance today. Although the growth of the rate of obese children has been stopped, the prevalence of childhood obesity remains alarming as approximately 17% of American children are diagnosed with this health condition (Ogden, Carroll, Kit, & Flegal, 2014). Childhood obesity is one of the primary concerns of the healthcare system due to the comorbidity of this disorder. Childhood obesity is associated with such chronic illnesses as hypertension, type 2 diabetes mellitus, insulin resistance, fatty liver disease, obstructive sleep apnea, and dyslipidemia, as well as low self-esteem, depression, anxiety, and behavioral disturbances (Weintraub et al., 2013). It has been acknowledged that these conditions persist in these people’s adulthood, which causes aggravating health issues and emotional distress for people and additional burden to the healthcare system.

The review of the existing literature indicates a lack of attention to such aspects as the frequency and the number of educational sessions aimed at increasing children’s physical activity. Thirty studies published between 2012 and 2018 were included. Such databases as GoogleScholar and PubMed were used when surveying the literature. The following keywords were used in different combinations: middle school, children, obesity, prevalence, comorbidity, intervention, educational, family involvement, community, ethnic and cultural diversity. The major inclusion criterion was articles’ publishing date. The focus was on middle-school students residing in the USA and diagnosed with obesity. Empirical studies were mainly included in this review. Secondary sources were used when the prevalence and comorbidity of the disorder were considered. Over 80 titles and abstracts were analyzed, while 30 articles met the inclusion criteria. The following five major concepts were identified: obesity, parents’ awareness, parental involvement, ethnic and cultural diversity, intervention, family and community involvement. This literature review includes a brief analysis of the mentioned concepts, including subthemes related to the research question of this study.

Obesity Prevalence and Comorbidity

The primary concept associated with the subject matter of the proposed study is obesity. Therefore, this aspect will be discussed first. The emerging subthemes related to childhood obesity and its prevention include prevalence, ethnicity as a risk factor, and comorbid conditions. It is necessary to note that the prevalence of childhood obesity in different periods is from the researchers’ lens. It is also noteworthy that such sub-categories as diversity and disparity are closely linked.

The articles reviewed in this section were based on longitudinal studies or analysis of statistical data. Therefore, the sample size of each study was several thousand participants, which can be regarded as sufficient evidence necessary to make conclusions concerning the disease prevalence and comorbidity. The study by Pulgarón (2013) is based on the analysis of approximately 500 articles on obesity, which is also a relevant source. Although such considerable sample sizes can be seen as a strength, they are also a certain kind of limitation. The studies lack the focus on prevalence by specific groups such as ethnicity, socioeconomic status, or specific comorbid conditions (Ogden et al., 2014; Pulgarón, 2013; Day, Konty, Leventer-Roberts, Nonas, & Harris, 2014; Springer et al., 2013). These areas should receive specific attention in future research as this information can help in the development of projects and interventions that address the specific needs of vulnerable populations.

Prevalence

As has been mentioned above, the rate of children diagnosed with obesity is considerable. Ogden et al. (2014) noted that 16.9% of children aged over five years were obese in 2012. In their study, Day et al. (2014) found that the rate of New York middle-school students diagnosed with severe obesity reached 5.7% in 2011. At the same time, Pulgarón (2013) argued that the data concerning obesity prevalence lacked certainty as some reviews were based on self-reports. Moreover, different measurements were used to estimate the rate of people with excessive body weight. It has been acknowledged that obesity has become an epidemic since the 1970s (Ogden et al., 2014). It is also stressed that various projects and programs have been developed and implemented to address this health issue, but it still persists.

Ethnicity as a Risk Factor

It is also acknowledged that ethnicity and cultural background are linked to obesity prevalence (Day et al., 2014; Dodd, Briefel, Cabili, Wilson, & Crepinsek, 2013; Springer et al., 2013). Such populations as Hispanic Americans and African Americans are specifically vulnerable due to some genetic predetermination and cultural backgrounds (Dodd et al., 2013). For instance, Hispanics consume rather fatty foods and sweetened beverages, which has a negative effect on their health (Springer et al., 2013). Moreover, these populations often live in low-income neighborhoods characterized by limited areas for physical training and recreation (Ogden et al., 2014). These families also have financial issues and can hardly afford healthy lifestyles.

Comorbidity

The subtheme of comorbidity is rather recurrent among studies associated with childhood obesity. Hypertension and type 2 diabetes are seen as the most common disorders related to childhood obesity (Weintraub et al., 2013; Flynn, 2013; Pulgarón, 2013). For instance, Flynn (2013) found that the prevalence of pre-hypertension state among middle-school children was 10% in 2012 and showed signs of increase. The researcher emphasized that hypertension had not been regarded as a disorder affecting children before the 2000s. Pulgarón (2013) identified such common health issues associated with obesity as cardiovascular illnesses, metabolic risk factors, psychological problems, and attention-deficit hyperactivity disorder.

Parents’ Awareness

Lack of Understanding

The concept of parents’ awareness is associated with such subthemes as the lack of understanding, hazards associated with physical inactivity, and the lack of responsibility. Parents’ (as well as educators’) perceptions concerning health, physical activity, diet, and similar aspects are linked to the effectiveness of interventions and programs aimed at promoting healthy lifestyles (De Craemer et al., 2013). This concept is explored within the domain of qualitative studies based on the use of semi-structured interviews. De Craemer et al. (2013) explored parents’ and educators’ views on physical activity, barriers and facilitators of physical activity, beverage consumption. Neely and Holt (2014) concentrated on parents’ perspectives concerning their children’s participation in organized sports. Perkins et al. (2017) examined parents’ ideas concerning the physical activity of their children with visual impairments.

The sample size in the studies mentioned above was rather limited except for the research by De Craemer et al. (2013) that involved over 200 participants. The studies by Neely and Holt (2014) and Perkins et al. (2017) involved several dozens of participants, making their generalizability rather doubtful. This is one of the primary limitations of the studies. The articles reviewed provide evidence concerning the lack of parents’ understanding of the benefits, opportunities, and hazards associated with the physical activity of their school-aged children. It is apparent that parents acknowledge the benefits of physical activity and healthy lifestyles but tends to concentrate on barriers rather than facilitators of the adoption of healthy behaviors. The focus on barriers is especially evident among parents of children with impairments. Perkins et al. (2017) concluded that parents try to remain protective and lack knowledge of the existing opportunities for their children. De Craemer et al. (2013) emphasized that parents often rely on teachers when it comes to the maintenance of healthy lifestyles and does not feel their responsibility to develop proper health-related habits. As for further research associated with this concept, it can be effective to implement quantitative studies to identify factors affecting people’s awareness, demographics, environmental and socioeconomic reasons for specific views.

Hazards Associated with Physical Inactivity

Physical activity is one of the most recurrent themes related to childhood obesity. It has been acknowledged that physical activity is closely linked to children’s boy weight mass (Hjorth et al., 2014; Iannotti & Wang, 2013; Fakhouri, Hughes, Brody, Kit, & Ogden, 2013). The studies by Iannotti and Wang (2013) and Fakhouri et al. (2013) provided quantitative data that involved over 10,000 participants each. In contrast, the study by Hjorth et al. (2014) had a sample of approximately 800 children. The sources mentioned above include evidence indicating that children started being more physically active in the 2010s, but the increase in physical activity varies across different ethnic groups. Iannotti and Wang (2013) found that Hispanic children and participants over 11 years old were less active than white children and younger participants. It is also noteworthy that although the relationship between physical activity and obesity is evident, physical inactivity is not regarded as the major predictor of the development of the disorder. For example, Hjorth et al. (2014) stressed that fatness predicted low physical inactivity, not vice versa.

Although the articles provide a substantial bulk of evidence, they lack precision regarding the way physical inactivity leads to obesity. The focus is also made on preventive measures and their effectiveness rather than particular hazards of physical inactivity in different age or ethnic groups (Iannotti & Wang, 2013). Future research should focus on the exact patterns of physical activity that can prevent childhood obesity and effectively address its negative effects.

The Lack of Responsibility

The aspect of the problem that receives significant attention is related to such domains as business, culture, families. The responsibility of businesses, agencies, as well as individuals and groups, is associated with childhood obesity and its prevention. In this respect, Callahan (2013) stated that the obesity epidemic could not be addressed without major societal shifts that should involve the changes in business strategies and corporate responsibility, cultural frameworks, and individuals’ mindsets. Lee, Van Dolen, and Kolk (2013) examined press releases of over 100 major brands and 6,302 blog posts related to these releases. The researchers argued that organizations had to fit more carefully their message related to corporate social responsibility and their core business. Lee et al. (2013) also noted that public opinion is still negative when it came unhealthy products and people tend to reveal their negative attitudes. Further research in this area may address the ways companies can align their core products and services with the public’s longing for healthier lifestyles. It can also be important to examine the most effective ways people may use to affect companies’ activities.

Parental Involvement

Another important facet of the research problem (the effectiveness of educational interventions for parents) is the concept of parental involvement. Lauricella, Wartella, and Rideout (2015) claimed that parents’ behaviors largely shaped their children’s views and health-related patterns. Encouraging parents to be more engaged in their children’s adoption of healthy lifestyles can and should be an element of educational programs aimed at increasing elementary school students’ physical activity. The articles where this concept emerged are characterized by the occurrence of such subthemes as parental involvement, physical activity and parental support, and cost-effectiveness of the corresponding programs (Lauricella et al., 2015; Liu et al., 2017; Epstein et al., 2014).

Parental Involvement

Lauricella et al. (2015) concentrated on parental involvement and its link to children’s screen time. Epstein et al. (2014) focused on an important but often ignored aspect of the problem, the cost-effectiveness of programs provided to parents and children. The studies mentioned above are characterized by the use of quantitative methodologies. The sample size of the research concerning parental involvement was substantial, ranging from over 100 to more than 2,000 people. Such tools as surveys, physical data, and financial information analysis were utilized (Lauricella et al., 2015; Epstein et al., 2014).

It is found that parental involvement is an important factor predicting better health outcomes for children. For example, Lauricella et al. (2015) stressed that children’s screen time is linked to their parents’ attitudes towards the matter and their behavior. Epstein et al. (2014) argue that interventions provided to parents or children separately are less cost-effective compared to the programs involving both parents and their children. As for the limitations of the study, the central one is the use of self-reporting as the data collection tool (Epstein et al., 2014). Another area to pay attention to is the lack of focus on other factors that may have an impact on children’s physical activity (friends, school-related models, media, and so forth). The recommendations for further research are mainly related to the inclusion of the analysis of different factors influencing children’s activity when exploring the relations between parental involvement and children’s health-related behavior.

Parental Support

The sub-theme of parental involvement is closely connected with that of parental support, but the latter implies specific family input in children’s lifestyles. This support may include funding children’s participation in sports, role modeling, and encouragement. Parental involvement is associated with accompanying children to sports events and participation in programs aimed at developing healthy lifestyles. The articles exploring parental support provide quantitative data that reveal the existing trend (Liu et al., 2017; Berge, Wall, Larson, Loth, & Neumark-Sztainer, 2013). Liu et al. (2017) examined the relations between parental support and their children’s physical activity. The study involved almost 82,000 schoolchildren. Liu et al. (2017) found a strong correlation between parental support (including but not confined to parents’ financial support, accompanying, encouragement, role modeling) and their children’s physical activity.

Berge et al. (2013) concentrated on psychological support, problem-solving, and communication. Almost 2,800 adolescents took part in the study. Berge et al. (2013) reported a strong link between effective family functioning and school students’ healthy lifestyles. The major limitation of the studies was the use of self-reporting as a data collection strategy (Berge et al., 2013; Liu et al., 2017). Some of the primary concerns related to the use of self-reports include different views on body weight status and family functioning. In simple terms, students’ evaluation of their parents’ support could be shaped by their socioeconomic status, family composition (single-parent or two-parent families), number of siblings, ethnicity, and cultural peculiarities. Further steps in this area should involve the identification of specific strategies used by parents to shape their children’s lifestyle as well as the effectiveness of these measures in different populations (in terms of gender, ethnicity, and socioeconomic status). It can also be beneficial to work on the development of effective research methods to address the issues mentioned above.

Peer Support and Media

The review of the literature on obesity prevention also unveiled the sub-theme of peer support and the role of the media. It is suggested that peer pressure often has adverse effects on middle-school students’ lifestyles, and social media play a significant role in the development of attitudes towards the matter (Fitzgerald, Heary, Kelly, Nixon, & Shevlin, 2013; Chou, Prestin, & Kunath, 2014). Fitzgerald et al. (2013) explored the way adolescents saw their lifestyles and the way they are affected by peers. Almost 500 participants revealed their perspectives. The major limitation of this study was its focus on self-reporting, which can be associated with rather distorted data (Fitzgerald et al., 2013). It was found that self-efficacy was linked to healthy lifestyles while peer pressure led to the development of unhealthy dietary habits.

Chou et al. (2014) analyzed 2.2 million posts on different social media platforms. It was found that Twitter was the most common channel for the discussion of obesity-related issues. Chou et al. (2014) also reported that Facebook and Twitter posts were characterized by explicitly derogatory attitudes towards obesity, while blogs and forums contained messages with implicit negative connotations. The major strength of the study by Chou et al. (2014) is its focus on attitudes towards obesity and the bulk of data collected. However, a significant limitation is the lack of attention to specific populations. It is necessary to identify the perspectives of middle-school students and the way these views are presented through the most common social media. As far as further research is concerned, it is essential to focus on such areas as peer support, role models, social media, and possible ways to use these concepts to address the prevalence of obesity.

Ethnicity

The impact of ethnicity and cultural peculiarities on parents’ attitudes and involvement is another emerging concept that is closely connected with such subthemes as parents’ attitudes, culturally appropriate interventions, and the outcomes for particular ethnic groups. Rawlins, Baker, Maynard, and Harding (2012) conducted a qualitative study that concentrated on the views of culturally diverse groups on healthy lifestyles. Fitzgibbon et al. (2013) implemented a quantitative study focusing on the effectiveness of a family-based program involving the Latino population. It is noteworthy that this program was designed for African American children. Bender, Nader, Kennedy, and Gahagan (2013) carried out quantitative research that explored the efficiency of an intervention developed to address obesity among Hispanic groups.

The studies mentioned above are characterized by a significant sample. The target population of the studies is diverse as Rawlins et al. (2012) include participants from different cultural backgrounds, while the other two articles provide data on the outcomes for the Latino population. Rawlins et al. (2012) many similarities in different groups’ views as parents of different backgrounds placed significant value on healthy lifestyles. The participants also mentioned similar barriers (for example, socioeconomic issues) to the adoption of healthy patterns. However, the researchers also point at significant differences concerning the view on healthy diets. Fitzgibbon et al. (2013) concluded that an intervention that was effective with African Americans turned out to be ineffective with the Hispanic population. Bender et al. (2013) described the positive results of their study that involved Latino mother-child dyads, although mothers’ progress was not very significant. The researchers added that further exploration of the effectiveness of the program that would cover a larger population was necessary.

The limitation of the qualitative study is a small sample size and the use of focus groups, which could result in a certain bias and lack of generalizability (Stewart & Shamdasani, 2014). Qualitative data collection is associated with considerable challenges as the moderator can be biased towards some views and attitudes, which may affect the way questions are set, or the overall discussion in focus groups occurs. Furthermore, the participants may provide socially desirable answers and give rather distorted facts as to their lifestyles (Stewart & Shamdasani, 2014). Researchers use various methods to ensure the reliability and validity of the data, such as triangulation or thick description. However, there is still some uncertainty when it comes to such sensitive topics as obesity.

Regarding this review, Fitzgibbon et al. (2013) concentrated on low-income and poorly acculturated Latino groups so that this homogeneity can have adverse effects on the generalizability of findings. Middle-class Hispanic Americans can have another view on healthy lifestyles and can be more concerned with their health. Bender et al. (2013) paid little attention to such factors as school, media, family when evaluating the effectiveness of their program. Further research may involve the evaluation of interventions developed to address the needs and peculiarities of specific ethnic groups. It can be important to include a more diverse sample in terms of socioeconomic status, educational background, and so forth.

Intervention

Another major concept associated with the proposed study is that of intervention. It is important to consider different aspects of other programs’ analysis to make sure that the methods used are effective and the focus of the study, if relevant. The concept of intervention is associated with the following subthemes: physical activity and screen time, physical activity and diets, low-income parents’ education. Jago et al. (2013) assessed the efficacy of an intervention aimed at improving children’s physical activity and reduce screen time. Nyberg et al. (2015) evaluated an educational program associated with children’s physical activity and dietary habits. Ontai, Lipscomb, Sitnick, Bowers, and Lamp (2013) also analyzed the effectiveness of an intervention aimed at improving physical activity and dietary patterns. However, the researchers focused on low-income families (Ontai et al., 2013).

The studies linked by the concept of intervention are characterized by the use of quantitative instruments. At the same time, Jago et al. (2013) used a mixed-method design in order to elicit the participants’ views on different aspects of the intervention and its outcomes. Jago et al. (2013) concluded that the program was effective as screen time decreased while the participants became more physically active. However, this research has a significant limitation as the sample size is rather limited.

Nyberg et al. (2015) found that the program had a positive influence on vegetable and fruit intake, but the effects on boys’ physical activity were more pronounced as compared to girls’ lifestyles. One of the central limitations of this study was the use of self-reporting that can be associated with a certain bias. Ontai et al. (2013) emphasized that the educational intervention for low-income parents was an effective strategy to promote healthy diets and physical activity. This study, as well as the research by Jago et al. (2013), has a considerable limitation as the programs lasted for several weeks. It is also necessary to note that all the interventions were implemented in communities that were rather homogeneous. As far as further research is concerned, it is essential to identify the elements of educational programs that have the most positive and well-established outcomes. In order to achieve this goal, it can be necessary to conduct quantitative studies that should cover as large a population as possible. The sample should also be diverse, while the focus can be on the cultural and socioeconomic peculiarities of different groups.

Family & Community

Finally, the concept of community and family should be taken into account when developing, implementing, and evaluating educational programs for parents. This construct is closely linked to such subthemes as community-based programs for parents and children, community-based interventions for fathers, environment. Timperio et al. (2013) paid close attention to the environment and overall opportunities for children’s participating in sports and different types of physical activity. The availability of sport-related resources at home and in the community is central to this study. Rito, Carvalho, Ramos, and Breda (2013) evaluated the effectiveness of a community-based educational program that involved parents and their children. The focus was on dietary habits and healthy lifestyles. Morgan et al. (2014) assessed an educational intervention for fathers and children delivered in the community setting. The aspects under analysis were health-related measurements (waist, blood pressure, weight) and self-reports on sedentary behaviors, physical activity, and diets.

The studies associated with the concept of community and family can be characterized by a similar limitation. All of them utilized self-reporting as a data collection tool, which could lead to a certain bias. Apart from that, long-term effects were not explored. Furthermore, Timperio et al. (2013) noted that their use of the term sports could be misinterpreted by children who could report on their participation in organized sports rather than their overall physical activity. Rito et al. (2013) stated that their participants were not properly randomized, and no control group was available. Therefore, the findings can be biased since the participants were committed to following recommendations and being active during the interventions. Further research can address such gaps as the barriers to the effective implementation of community-based interventions. It is also critical to examine the long-term effects of educational programs.

Conclusion

This review of the literature identified the peculiarities of the existing research on educational interventions for parents aimed at increasing their children’s physical activity. The central areas of concern are parents’ awareness, parental involvement, ethnic diversity, interventions per se, family and community involvement, the role of peers, and the media. It is clear that various interventions have proved to be effective in reaching the goal mentioned above. However, there are certain gaps yet to be addressed. It is necessary to evaluate interventions involving large samples that are diverse. It can be essential to pay specific attention to people’s cultural peculiarities. The long-term effects of programs and interventions should also be properly explored. Finally, researchers should consider using diverse data collection methods in order to assess the programs in question.

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