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Child and Parent Nutrition Knowledge,
Behavior, and Attitude
By
Tami Langmeier
A Research Paper Submitted in Partial Fulfillment of the
Requirements for the Master of Science Degree
111
Food & Nutritional Sciences
Approved: 2 Semester Credits
The Graduate School
Universi ty of Wisconsin-Stout
May, 2009
Author:
Title:
The Graduate School University of Wisconsin-Stout
Menomonie, WI
Langmeier, Tami A.
Child and Parent Nutrition Knowledge, Behavior, and Attitude
Graduate Degree/ Major: MS Food and Nutritional Sciences
Research Adviser: Ann Parsons, Ph.D.
MonthrYear: May, 2009
Number of Pages: 99
Style Manual Used: American Psychological Association, 5th edition
ABSTRACT
No longer are obese adults the topic of conversation. The reason being is that the
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alarming rates of childhood obesity have unfortunately stolen the spotlight. Data from
the last 26 years indicate that obesity rates among children, aged 6 to 11, has more than
doubled, and for adolescents, aged 12-19, rates have more than tripled. Childhood
obesity is of such dire concern due to the future implications it imposes in terms of the
increased risk and early onset for adult-associated health problems. Family-based
interventions have shown promise in being an effective method of treatment for
childhood obesity. A six week, ten session, family-based intervention designed around
providing nutrition education and increasing physical activity was conducted for families
in Dunn County who had at least one child who was overweight or at risk. Each family
member completed a Hearts N' Parks questionnaire that focused on nutritional
knowledge, behavior, and intentions. The study evaluated 17 children, between the ages
iii
6-12 years, and 19 parents. Pearson correlation coefficients were analyzed to determine
if any relationships existed between nutrition variables for either children or adults, and,
more importantly, to determine if any relationship was present between parent and child.
Data collected for children found a positive and significant relationship between a
child's behavior and intentions. Several significant relationships were found amongst
parent data, however, all but one was of negative origin, and no significant relationships
were found between the parent and child data. Interestingly, however, was the number of
negative relationships present between the two.
The Graduate School
University of Wisconsin Stout
Menomonie, WI
Acknowledgments
IV
There is no doubt that this has been a long, tedious process and one that could not
have been done without the help of so many people. First and foremost, I have to thank
my thesis advisor Dr. Ann Parsons, UW-Stout Associate Professor. Not only did she
provide constant feedback and support, but she was able to do so over 1,000 miles away
while I was finishing my internship in Georgia. Her passion to create awareness and
programs for families with overweight or at risk children is truly inspiring. Being
involved in this intervention process was one that I will never forget and one that I plan
to reflect on for many years to come.
I would also like to thank statistical consultants, Christine Ness for helping me
enter my data, and Susan Greene for making the results so easy to interpret. I would have
been lost in data without you. A special thanks goes out to Leah Karaliunas, my partner
in crime! Not only did Leah help get this project off the ground, but she was such an
amazing support and motivator.
Last, but certainly not least, I have to thank the entire behind-the-scenes support
system starting with my boyfriend Andy. Thank you for calming me down when I
wanted to scream, motivating me to keep going, and most of all for believing that I could
do this. A special thanks to my sister Tara and best friend Jackie for their endless hours
of proofreading and listening. Lastly, I have to thank my parents, family, and friends for
their constant love and support. I couldn't have completed this without it.
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TABLE OF CONTENTS
...................................................................................................... Page
ABSTRACT ......................................................................................... .ii
List of Figures ..................................................................................... viii
Chapter I: Introduction ............................................................................. 1
Statement of the Problem .................................................................. 6
Research Questions ......................................................................... 6
Assumptions of the Study ................................................................. 6
Definition of Terms ......................................................................... 7
Limitations of the Study ................................................................... 8
Methodology ................................................................................. 9
Chapter II: Literature Review .................................................................... 10
Introduction ................................................................................ 1 0
Risk Factors .............................................................. ................... 10
Social Implications . ........................................................................ 14
Contributors of Childhood Overweight ................................................ 15
Genetics ..................................................................................... 16
Behavior & Environmental Factors ..................................................... 18
Portion Sizes . ............................................................................... 18
Sweetened Beverages .................. , ................................................... 20
Physical Inactivity ... ........................................................ , ....................... 21
Television/Video Games/Computer Usage ............................................ .22
Snacking .................................................................................... 23
VI
Advertisements .............................................................................. 23
Parental Involvement and Family Dynamics ............................................ .24
Feeding Behaviors ..................... , ................................................... 27
Family Meals ................................................................................ 28
Interventions Factors ...................................................................... 29
Chapter III: Methodology ........................................................................ .31
Subject Selection and Description .................. , .................................... 31
Instrumentation ............................................................................ 31
Data Collection Procedures ............................................................. 34
Data Analysis .............................................................................. 34
Limitations ................................................................................. 35
Chapter IV: Results ................................................................................ 37
Demographic Information ............ , ................................................... 37
Research Objectives .......................... ............................................. 37
Table 1: Correlations present between parent data .................... .............. .43
Table 2: Relationships between parents and children ... ............................. .45
Chapter V: Discussion ............................................................................. 46
Limitations ................................................................................. 46
Conclusions ................................................................................ 47
Correlations of Children's Variables .................................................. .47
Correlations of Parents' Variables ..................................................... .48
Correlation between Parent's and Child's Variables ................................ 50
Recomnlendations ........................................................................ 52
Vll
References .......................................................................................... 56
Appendix A: IRB Approval Form .................................................................. 73
Appendix B: Informational Flier for Recruitment ............................................... 75
Appendix C: Informational Packet for Families ................................................ 77
Appendix D: Informed Consent .................................................................. 80
Appendix E: Letters to Councilors and Teachers ............................................... 82
Appendix F: Child Questionnaire .................................................................. 84
Appendix G: Adult Questionnaire ................................................................ 88
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List of Figures
Figure 1: Total nutrition scores for children's knowledge, behavior, and intention ....... 38
Figure 2: Number of nutrition questions answered correctly ................................. 38
Figure 3: Correlation between children's healthy eating behavior and intentions .......... 39
Figure 4: Total nutrition scores of parents' healthy eating knowledge, behavior, and
attitudes ................................................................................... 41
Figure 5: Total nutrition scores of parents' overweight/obesity knowledge and attitudes 41
Chapter One: Introduction
"Never before has there been a generation in which so many kids are so heavy so
early in life," stated Dr. David Ludwig (2007), author of Ending the Food Fight and
founder of the Optimal Weight For Life Program (p. 10). The crisis our children are
facing reflects the overweight and obesity epidemic that currently affects the nation's
adult population. With children, however, the stakes are much higher, not only because
children will be carrying more weight for a longer period of time, but also because
overweight is "occurring during the critical stages of childhood growth and development"
(p. 10), therefore the consequences for overweight and obese children will be much
greater.
The Director of the National Institute of Child Health and Human Development,
Dr. Duane Alexander (2006) stated that "contrary to popular belief, young children who
are overweight or obese typically won't lose the extra weight simply as a result of getting
older" (1 3) as previously expected. Researchers have found that the more times a child
enters into a BMI category over the 85th percentile, the greater their chances are for
remaining overweight into adolescence (Nader et aI., 2006). Follow-up calculations from
this study determined that 2 in 5 children who had a BMI greater than or equal to the 50th
percentile by the age of 3 were overweight by the age of 12. The outcomes ofthis study
highlight the need for early intervention and the need to limit the progression of abnormal
weight gain in early childhood due to the many underlying health complications that are
associated with excess weight.
The World Health Organization (WHO) projected that by the year 2015,2.3
billion adults will be overweight and a staggering 700 million will be obese (2006).
2
Where do children fit into this picture? According to the Internal Obesity Task Force
(IOTF), at least 155 million school-age children from around the world are overweight or
obese, with 22 million of those children being under the age of five (n.d). When thought
of in tenns of the associated health implications that our children will face as a result of
carrying excess weight, this number is truly devastating. Evidence suggests that in the
next few decades, childhood obesity alone may shorten a person's life expectancy by up
to five years, a number that is estimated to be equal to the impact of all cancers combined
(Ludwig, 2007).
Pediatricians are now regularly diagnosing children with obesity-related
conditions that used to occur only in middle-aged and elderly adults, conditions such as:
high blood pressure, high cholesterol, fatty liver, sleep apnea, and type 2 diabetes.
The clustering of these risk factors, commonly referred to as metabolic syndrome
is what has society more concerned than ever. Mayo Clinic defined metabolic syndrome
as a "cluster of conditions that occur together, increasing your risk of heart disease,
stroke, and diabetes" (~ 1, 2007). The risk factors that the tenn commonly refers to
include: obesity, hypertension, impaired fasting glucose, hypertriglyceridemia, and
reduced high-density lipoprotein cholesterol (Huang, 2007). Once only associated with
the adult population, metabolic syndrome is now found in approximately 4% to 7% of
children and adolescents, and up to 49% of severely obese youth (Pan & Pratt, 2008),
posing a serious threat to the current and future health of our youth.
As the rates of childhood obesity have increased, so too has the diagnosis of type
2 diabetes among children (Schwartz & Chadha, 2008). Type 2 diabetes develops due to
extra fat tissue putting excessive demands on the body to make insulin, which can result
3
in an individual becoming insulin resistance. According to Hossain, Kawar, and EI
Nahas (2007), about 90% of type 2 diabetes cases are attributable to excess weight,
meaning it is a disease that can be minimized, if not avoided, by maintaining a healthy
weight.
In the past, obesity has been blamed solely on the individual according to
Schwartz and Brownell (2007) in that obesity is a consequence of failure of "personal
responsibility" (p.79). However, researchers have indicated that obesity is caused by a
combination of several factors stemming from genetics, environment, and behavior, and
as a result, making it more difficult to maintain a normal weight. These factors may
make it increasingly difficult for children to overcome due to the lack of control and
influence they face in their early lives.
The thrifty genes, more commonly known as "fat genes" (Ludwig, 2007, p. 11),
enabled humans many years ago to gain extra weight when food was plentiful, so that
they were able to survive during times of scarcity. Scientists proposed that these genes
were favored by evolution and passed down to future generations. But through society's
own evolution of abundance, these genes are the same ones that contribute to becoming
and remaining obese (Bray & Champagne, 2005; Ludwig, 2007).
The epidemic of obesity does indeed occur on a genetic background and genetic
factors clearly influence an individual's predisposition to be heavy, but our genes haven't
changed over the past three decades. The thing that has changed is the environment in
which we live, a "toxic environment," according to Kelly Brownell of Yale University
(cited in Ludwig, 2007, p. 13). "The toxic environment overwhelms our weight control
systems (biology) and undermines our willpower (psychology), making it almost
4
impossible to eat and stay physically active (behavior). As a result, children gain excess
weight" (p. 17).
In the modem American home, cabinets are stockpiled with processed foods and
snacks; vegetables no longer fill their intended bins; garbage cans are filled to the brim
with pizza boxes, soda cans, and wrappers from fast food establishments. Parents are
stressed and drained of energy after a day of work, and find that it is more convenient to
stop on the way home from work for a carryout meal rather than take time to make a meal
that the family can sit down and enjoy together (Schwartz & Brownell, 2007). The
portion sizes of these typical meals are gigantic, and the soda cups have more than
doubled in size. Fast food, sweets, and soda were once considered occasional treats, but
in the last twenty years have become a staple in our American diet (Ritchie et aI., 2005).
To make matters worse, children are also now watching more television than ever, not to
mention the time spent playing video and computer games, and are becoming more
inactive as a result (Temple et aI., 2007).
Children have not only seen a change in their household over the years, but the
atmosphere in schools has changed as well. Vending machines that contain chips, candy,
and soda now line the hallways tempting students at every tum. These unhealthy foods
are everywhere, and worst of all they taste good, which can be a seductive combination
for children according to Ludwig (2007). Schools facing financial hardship have
franchised the cafeteria to fast food chains at the expense of our children's health. They
have also cut many physical education classes and after-school activities due to tight
budgets. The kind of food served in schools, as well as the decrease in physical activity,
does nothing but reinforce children's unhealthy eating habits.
5
Schools are often times seen as being responsible for children due to the fact that
the majority of children spend most oftheir waking hours there. In recent years, schools
have assumed an overwhelming amount of responsibility for the actions of children that
expand far beyond academics. Eventually however, the responsibility needs to shift to
the behaviors of the caregiver and society.
What role do parents play in the current obesity epidemic? Many parents may
feel it is against nature to deny his or her child something as fundamentally nurturing as
food. Food, however, has become more than a biological necessity; it has become
emotional expressions oflove, insecurity, and control (Snoek et aI., 2007). Food is
essential to human survival, and a parent's primary role is to ensure the survival of the
next generation, so it doesn't seem fitting to deny our key source of survival, food. Satter
(2005), however, states the role of parents is to simply provide "structure, safety, and
opportunities" (p. 19). When it comes to feeding, "parents are responsible for the what,
when, and where of feeding," while "children are responsible for the how much, and
whether of eating" (p. 10). This division of responsibility, while seemingly a simple
concept, may not be so straightforward or easy to abide by, especially if dealing with an
overweight child.
The role of parenting is especially vital for young children because parents
directly dictate the child's social and physical environment, and therefore are the first line
of defense in the prevention of childhood obesity according to Ritchie and colleagues
(2005). For that reason, family-based interventions that emphasize reasonable and
coordinated goals for both the parent and child are a logical approach in terms of
6
prevention and treatment options for childhood obesity (Golan & Crow, 2004; St. Jeor et
aI., 2002; Wrotniak et aI., 2004).
Statement of the Problem
The purpose of this study was to determine if any relationships existed between
one's nutrition knowledge, behavior, and intentions, as well as any correlations between
parent and child across these parameters. Data was collected in Dunn County, Wisconsin
in March of2007. Information was obtained through the use of Hearts N' Parks Survey.
Research Questions
There are three research questions this study will attempt to answer. They are;
1. Do any correlations exist between a child's nutritional knowledge, behavior,
and/or intentions?
2. Are any correlations present between a parent's nutritional knowledge, behavior,
and/or attitude?
3. Does a child's knowledge, behavior, and/or intentions emulate his/her parent's
knowledge, behavior, and/or attitude in regards to dietary practices and beliefs?
Assumptions of the Study
It is assumed that families who participated in the intervention were made up of
the basic family unit (at least one parent/guardian and at least one child) with one or more
child at risk for overweight or obesity and in need of nutritional guidance and support. It
was also assumed that participants completed the questionnaires honestly, accurately, and
as completely as possible.
7
Definition of Terms
There are tenns that need to be defined for clarity of understanding. They are as follows:
At Risk for Overweight: Over optimal body weight for a child, but not currently in
the overweight category.
Body Mass Index (BMI): BMI is used to screen for obesity, overweight, healthy
weight, or underweight and is defined as weight in kilograms divided by the square of
height in meters
CDC: Center for Disease Control
CHD: Coronary heart disease
Comorbidity: One or more disorders present in addition to a primary disease or
disorder.
CVD: Cardiovascular disease
Energy-Dense: Amount of energy (kilojoules or calories) per amount of food,
with food amount being measured in grams or milliliters of food.
Habituation: Psychological process in humans in which there is a decrease in
behavioral response to a stimulus after repeated exposure to that stimulus over a duration
of time.
Microcosm: Anything that is regarded as a world in miniature.
Normal Weight: Optimal body weight; categorically defined for children as
greater than the 5th percentile to less than the 85th percentile.
Obesity: Defined as a BMI-for age at or above the 95th percentile for children of
the same age and sex. For adults, it is defined as a BMI of 30 or greater.
8
Overweight: Defined as a BMI-for-age at or above the 8Sth percentile and lower
than the 9Sth percentile. For adults, it is defined as a BMI of2S-29.9.
Underweight: Body weight less than optimal; categorically defined for children
as BMI-for-age less than the Sth percentile. For adults, it is defined as a BMI ofless than
18.S.
NICHD: National Institute of Child Health and Human Development.
NIDDK: National Institute of Diabetes and Digestive and Kidney Diseases.
z-BMI: Body mass indexes standardized for mean (M) and standard deviation (SD)
(z-BMI=[BMI-M]/SD)
Limitations of the Study
A limitation of the study would be the inability to extrapolate the findings to
larger populations due to extremely small sample size and the lack of ethnic diversity
among study participants. The 200S-2007 American Community Survey conducted by
the U.S. Census Bureau estimated Dunn County to be comprised of9S.S% Caucasian
individuals; leaving a mere 4.S% combined from all other races. Another limitation to
the study may have been in the method of program information dispersal. School
counselors and/or teachers may have been hesitant in recommending families who had
children that were overweight or at risk for becoming overweight due to the sensitivity of
the subject. Also, letters that were sent home with children may not have made it to the
intended recipient. As a result of poor community response, the goal of 20 families was
not met and therefore all interested families were included, which meant that families
were not chosen at random.
9
Methodology
The methods of this study required the participation of children who were
considered overweight or at risk for overweight as well as the participation of that child's
parent or guardian. Letters were sent to all families in Dunn County who had a child
attending a public grade school that was between the ages of 8-10 years. Families who
showed interest in the intervention were then instructed to contact either Jan Pejsa from
the Red Cedar Medical Center or their child's school counselor or teacher for additional
program information. Families were then to sign an informed consent form if they
wished to participate in the intervention. Data was collected at the first of ten sessions
through the use of the Hearts N' Parks questionnaires in order to assess parents and
children's nutritional knowledge, behavior, and intentions. Posttest data was collected
during the last session, however, was not included in this particular study.
10
Chapter Two: Literature Review
This chapter will include a discussion on why childhood obesity is considered an
epidemic and how overweight and obesity affects children in their young lives and into
adulthood. It will include a discussion of the possible contributors that place a child at
increased risk for being overweight and/or obese. It will also describe genetic, behavioral,
and environmental determinants, and how they affect childhood obesity. Finally, the
chapter will conclude with a discussion on the importance of parental involvement and
family dynamics in the efforts to change childhood obesity.
Introduction
Society has undergone a considerable transformation in the past 20 years. These
changes have directly and drastically influenced the way people live, eat, and play. As a
result, the nation is experiencing what many call an obesity epidemic. According to the
American Academy of Pediatrics, approximately 9 million children older than six years
of age are obese (citied in Hassink, 2006). Internationally, it was estimated in 2001 that
22 million children under the age of five were overweight, a number that has likely
increased in the last eight years (Deckelbaum & Williams, 2001). According to the
Obesity Society (2007), not only are more children becoming overweight, but also the
heaviest children are getting heavier.
Risk Factors
Why is all of this information so troubling and what does it mean for our youth?
In 2003, the director of the federal Centers for Disease Control and Prevention, declared
obesity as the number one health threat facing the United States (cited in Okie, 2005).
For many overweight children, this could signal future health issues. The comorbidities
11
that overweight and obese adults currently suffer from are similar to the ones our children
will be facing, but at a much earlier age.
In his Optimal Weight for Life (OWL) clinic, Dr. David Ludwig (2007) witnessed
firsthand a family who he referred to as the "microcosm of the 21 st century America" (p.
1). In this family, one of the parents was overweight, while the other was obese. The
five children were severely obese and according to Ludwig, had "numerous weight
related complications" (p. 1). Ludwig documented the following observations, "One of
the children had evidence of fatty liver, one had high blood pressure, two had
gastroesophageal reflux, two had orthopedic problems, three had marked insulin
resistance, four had dyslipidemia, and all had emotional problems related to their weight"
(p.l). This encounter highlights the seriousness of our nation's current obesity epidemic,
because the comorbidities mentioned above are no longer complications we are worried
about our children facing someday, they are complications that children are dealing with
at this present moment.
Metabolic syndrome, which was previously defined as a clustering of risk factors,
has emerged as a "major public health problem," according to Pan and Pratt (2008), due
to its adverse health consequences (p. 276). In 2004, Weiss et al. concluded in their
research that metabolic syndrome is far more common among children and adolescents
than previously reported, and that its prevalence increases directly with the degree of
obesity. In fact, the prevalence of metabolic syndrome was 38.7% in moderately obese
subjects and 49.7% in severely obese subjects.
Metabolic syndrome is associated with increased risk for type 2 diabetes and
cardiovascular disease in adults (De Farranti & Osganian, 2007). In children, however,
12
the correlations are not so clear due to the lack of studies that have directly explored the
impact of metabolic syndrome on disease outcomes in childhood. However, Cruz and
Goran (2004) concluded in their review of studies that "the high prevalence of metabolic
syndrome among overweight youth coupled with the epidemic increase in childhood
obesity could lead to a disproportionate increase in cardiovascular disease in adulthood"
(p. 56). Autopsy studies have confirmed this belief by revealing an association between
overweight in adolescence and accelerated coronary atherosclerosis (McGill et aI., 2002).
In a cohort study done in 2005, Wilson et aI. found that metabolic syndrome accounted
for up to one third of CVD in young men and approximately half of new type 2 diabetes
cases over an 8 year follow-up period. The study concluded that the relative risk of
incident for type 2 diabetes was greatly increased in persons with metabolic syndrome.
This data highlights the need for proper screening, prevention, and intervention especially
due to the fact that the long-term health implications of metabolic syndrome; CVD, and
diabetes in children are yet to be fully understood.
As the prevalence of childhood obesity increases, the health implications have
become even more evident, and according to Weiss and Kaufman (2008), one of the
earliest alterations is the abnormalities of glucose metabolism. "More than any other
factor, it is the rapid increase in type 2 diabetes among children and teenagers that has
awakened doctors and health officials to the grim future consequences of the obesity
epidemic" (Okie, 2005, p. 16). Type 2 diabetes was once more commonly referred to as
adult-onset because it almost always affected the adult population. Since the increase in
childhood obesity, however, it is now referred to as type 2 diabetes due to the fact that it
13
is now the most dominant fonn of diabetes in children and adolescents (Deckelbaum &
Williams, 2001).
Diabetes complications extend far beyond high blood sugars. In fact, diabetes
increases the risk of not only macrovascular complications such as cardiovascular
disease, but it also increases the risk of mircovascular complications which include
retinopathy, nephropathy, and neuropathy. As a result of these associated complications,
diabetes mellitus is the leading cause of new cases of blindness, kidney disease
nontraumatic lower-extremity amputation in individuals aged 20-74 years (CDC, 2007).
If that wasn't serious enough, according to the CDC, the risk of death among people with
diabetes is approximately twice that of people without diabetes. According to Ludwig
(2007), children who develop type 2 diabetes face the devastating prospect of
experiencing a heart attack, kidney failure, amputation, and/or other life-threatening
complications before the age of thirty. While counseling an overweight fifteen year-old,
Dr. Ludwig stated,
It's one thing for an obese forty-five-year-old to develop type 2 diabetes by age
fifty-five and suffer complications at age sixty-five. It's quite another thing for an
overweight fifteen-year-old to develop diabetes in his early twenties and have a
heart attack in his thirties. (2007, p. 33)
Overweight and obese adults have been suffering the complications of
cardiovascular disease for years now. In fact, results from the NHANES study done
through 2005-2006 estimated that 80,000,000 people in the United States had one or
more fonns of cardiovascular disease (high blood pressure, coronary heart disease,
stroke, and heart failure), which accounted for 35.3% of all 2,448,017 deaths in 2005
14
(American Heart Association, 2009). While these statistics are based off adults, we must
recognize that our children could soon be facing a similar fate.
According to Baker, Olsen, and Sorensen (2007), the risk factors for heart disease
are unfortunately already identifiable in overweight children. In a population-based
sample of 5-17 year-olds, approximately 70% of obese children had at least one risk
factor for cardiovascular disease, while 39% of obese children had two or more
cardiovascular risk factors according to Freedman et al. (2007). In a population-based
cohort study of276,835 children, researchers found that higher childhood BMI values
elevated the risk of having a CHD event in adulthood, and that even a small amount of
weight gain increases this risk (Baker, Olsen, & Sorensen, 2007). This same study,
which covered a 46-year period, found that 10, 235 men and 4,318 women suffered from
a CHD event; 4,104 which were fatal. When it comes to obesity related mortality, obese
individuals are at a 10-50% increased risk, with most of the increased risk due in part to
cardiovascular diseases (NIDDK, 2007).
Social Implications
Not only is childhood overweight and obesity associated with metabolic health
risks, it can also bring about social repercussions. There is no doubt that early
adolescence is a crucial time for the development of self-esteem and self worth, and that
dealing with ordinary changes during this time period is difficult in itself. Research has
shown that children with higher BMI's suffer from more depressive symptoms and
experience behaviors of degradation and ridicule (Sjoberg, Nilsson, & Leppert, 2005).
Janssen and colleagues (2004) found that overweight and obese children were more likely
15
to be the victims, and at times perpetrators, of verbal, physical, and relational bullying
than their normal-weight peers.
Adolescence is a time period when the approval from one's peers becomes
particularly important to the development of self esteem, because children rely so heavily
on the physical cues in their social environment (Strauss, 2000; Janssen et aI., 2004).
Schwartz and Brownell (2007) found that people who rationalize the overweight bias and
discrimination may also believe that negative treatment is deserved and should be used as
motivation for overweight individuals to lose weight. However, it is quite the opposite.
In fact, researchers have found that weight bias may actually intensify obesity through
increased depression and binge eating (Eisenberg, Neumark-Sztainer, & Story, 2003). In
a school-based sample of 4,746 adolescents in grades 7 through 12, researchers found a
consistent relationship between teasing about body weight and low body satisfaction, low
self-esteem, high depressive symptoms, and a 2-3 times higher rate of suicide ideation
and suicide attempts (Eisenberg, Neumark-Sztainer, & Story, 2003). It doesn't end there,
however. A study conducted in 1981, before the rapid increase in childhood obesity,
found that obese persons were highly stigmatized in the U.S., not to mention finished
fewer years of school, married less, and had lower household incomes (Gortmaker et aI.,
1993). If that was the case back then, one can only imagine the impacts of being
overweight and obese in today's world.
Contributors of Childhood Overweight
Childhood overweight, as defined by the Center for Disease Control and
Prevention (2009), is the result of an imbalance between the calories a child consumes as
food and beverages and the calories a child uses to support normal growth and
16
development, metabolism, and physical activity. Because energy can neither be created
nor destroyed as the law of thermodynamics states, we have the ability to store energy as
a result of the imbalance between intake and expenditure (Speakman, 2004) which in tum
can result in a person becoming overweight or even obese.
What does it mean to be in energy balance and is it even truly attainable?
According to Bray and Champagne (2005), we are never truly in energy balance, and
therefore this idea is simply an ideal rather than a realistic goal to be obtained. They also
stated that if managing overweight and obesity was simply a matter of energy balance,
the solution would be simple: "eat less and exercise more" (p. SIS). The idea of energy
balance implies that overweight and obesity are in fact a consequence of failed personal
responsibility just as Schwartz and Brownell (2007) noted in their symposium on
Creating the Climate for Change. In other words, this implies that children are the ones
to blame for their obesity (Bray & Champagne, 2005), and that concept doesn't seem
likely or more importantly, doesn't seem fair. As many would agree there are many
factors that contribute to overweight and obesity. Genetic, behavioral, and environmental
factors all playa role in the caloric imbalance that is contributing to our nation's obesity
cnsls.
Genetics
There is no doubt that genes playa critical role in the susceptibility of developing
obesity. Not all children are obese, however. Wardle et al. (200S) stated that the
"difference could be due to inherited genetic differences between children" (p.39S).
They went on to state that the difference could also be the result of differences in
children's "rearing environments" (p.39S).
17
In the case of genetics, Wardle et al. (2008), found in a twin analyses that in
preadolescent children born since the inception of the obesity epidemic, adiposity was
highly heritable The results from this study and other cohorts of young adults indicate
that the balance of genetic and environmental effects is basically the "same as that before
the external environment became so obesogenic" (p.401).
David Allison and a team of researchers from St. Luke's-Roosevelt Hospital
Center at Columbia University estimated that genes accounted for 75-80% of children's
percent body fat, while non-shared environmental influences contributed to the remaining
20-25% (Faith et aI., 1999). It is obvious that the combination of genetics and
environmental factors has an effect on energy balance and obesity, however, Speakman
(2004) stated that the effects are due to our adopted behaviors and physiology rather than
our genes alone.
How does family history factor into the prevalence of childhood obesity? Along
with many other risk factors, family history can be used as an indicator of obesity due to
the fact that obesity may run in the family. If one parent is obese, a child has a threefold
greater risk of becoming overweight, while the risk of a child with two obese parents
rises by more than tenfold (Hassink, 2006). The American Academy of Pediatrics stated
that for a child younger than three years of age, the presence of obesity in his or her
parents is a stronger predictor of whether he or she will become obese in adulthood,
rather than his or her present weight (Has sink, 2006).
Childhood overweight is likely to result not from genetics alone, but from an
interaction between environmental and genetic factors. Bray and Champagne (2005)
used an analogy to explain this interaction, "genes load the gun and a permissive or toxic
18
environment pulls the trigger" (p.S21). John Speakman (2004), author of Obesity: The
Integrated Roles of Environment and Genetics, stated that
" although we might say that obesity has a large genetic component to it, this
doesn't mean that the obese have somehow miraculously deposited enormous
quantities of body fat without eating too much food, expending too little energy,
or doing both" (p.2092S).
The dramatic increase in the rates of obesity among diverse youth from early
childhood throughout adolescence, in only a 20 year span, point to the predominant role
played by the ever-changing environment exerting its effects on a "stable genetic
susceptibility" (Ritchie et al., 2005, p. 70). Human genetic characteristics have not
changed in the last three decades, but the prevalence of overweight school-age children
has tripled during that same time indicating a much larger force than genetics alone
(CDC, 2009).
Behavioral and Environmental Factors
There is no doubt that contributing factors related to obesity interact with one
another, therefore, making it difficult to specify one behavior as the "CUlprit" of
overweight. Certain behaviors are more likely than others to contribute to the energy
imbalance our children are currently experiencing. In addition, the combination of
behavioral and environmental factors may have more than just an additive affects.
Portion Sizes
Just as the prevalence of overweight has increased dramatically in past decades,
so too have the portion sizes in our Western culture. Researchers from the Department of
Nutritional Sciences at Pennsylvania State University reported that fast food items have
19
been estimated to be 2 to 5 times larger than 2 decades ago (Young & Nestle, 2003), and
unfortunately it is in these fast food restaurants where larger portion sizes are most
commonly consumed (Colapinto et aI., 2007). Research has also shown that not only do
children overeat when eating out, but they also consume more calories from fat and
saturated fat according to Zoumas-Morse et aI. (2001). To make matters worse, families
are eating in these establishments now more than ever. Restaurant sales were estimated
to reach a shocking 566 billion dollars in 2008 (National Restaurant Association, 2009),
which gives an indication of the increase in popUlarity and hence consumption among
society. While these numbers do not paint the entire picture of where and what
consumers are spending their money on, it can be assumed due to the obesity epidemic
that it may not be of the healthiest sort.
What makes all of these statistics so troubling is that researchers have found that
the portions sizes consumed by children with higher BMI's were as much as 100% larger
than portions consumed by children with lower BMI's (McConahy et aI., 2002). Even
worse is that when children are served larger portions, they generally do not rate their
hunger or satiety levels any different than when they were served smaller portions (Rolls
et aI., 2004), indicating that these signals are being overridden and even ignored (Kral,
Roe, & Rolls, 2004).
Is it the portion sizes we should be so concerned about or the food choices that
children tend to eat larger portions of? Colapinto et aI. (2007) conducted a study on
children's preferences for large portions and the results were truly unsettling.
Researchers found that 63.5% of children chose larger portions of french fries, 77.9%
chose larger portions of meat, and 78.2% chose larger amounts of potato chips.
20
However, when it came to vegetables, 52.3% of children chose portions sizes that were
less than or equal to the guidelines. Based on the previous findings, Colapinto et al.
(2007) concluded that when it comes to large portion sizes, adverse affects can be seen in
terms of high energy intakes and overall poor diet quality.
Sweetened Beverages
Behaviors such as excessive consumption of beverages that contain high amounts
of sugar playa large role in our current obesity epidemic. The problem with calories in
liquid form is that children and adults do not generally compensate for the calories
consumed in sugar-laden drinks, and because they may be less satiating, consumption
may lead to a higher daily caloric intake. According to Marion Nestle (2006), soft drink
consumption alone makes up more than 10% of caloric intake, which is more than double
what it was in 1980. The U.S. Department of Agriculture stated that "even babies
consume measurable quantities of soft drinks, and pediatricians say it is not unusual for
overweight children to consume 1,200 to 2,000 calories per day from soft drinks alone"
(cited in Nestle, 2006, p.2).
A large, nationally representative study by Troiano et al. in 2000 conducted on
children ranging from ages 2-19, found that overweight was positively correlated to
percent of calories obtained from soft drinks. To further support the association between
beverage consumption and excess weight, a study done by LaRowe, Moeller, and Adams
(2007) placed children, ages 6-11, into beverage patterns and found that sweetened drinks
and sodas made up roughly 25% oftheir daily intake. These children, not surprisingly,
had the highest BMI; suggesting that high intakes of calorically sweetened beverages
may in fact lead to excess energy intake and therefore result in overweight. In fact,
21
Ludwig, Peterson, and Gortmaker (2001) concluded in their study that the odds ratio of
becoming obese as a child increased from 1 to 6 times for each additional can or glass of
sugar-sweetened drink that a child consumes every day, and that does not include the
infamous "Big Gulp."
Physical Inactivity
Not only have our eating habits transformed over the past twenty to thirty years,
but our activity level has undergone considerable change as well. Unfortunately, that
change has had a dramatic effect on the weights of our children. The sedentary lifestyles
oftoday's children in western society are among the major contributors to the increased
prevalence of childhood obesity (Nemet et aI., 2005).
Generations ago, parents generally didn't give much consideration to whether or
not their children were physically active. Back then, according to Hassink (2006),
children came home from an active day at school, grabbed a quick snack, and were out
the door again to go play with their friends until dinner. Now, however, children are
engaging in less physical activity during school due to budget and program cutbacks, and
therefore participation in school-related physical activity has decreased according to CDC
(2008). The Youth Risk Behavior Surveillance Summary (YRBSS) conducted by The
Department of Health and Human Services and Center for Disease Control and
Prevention found that 65% of high school students did not meet the recommended levels
of physical activity. The survey also found that 46% did not attend physical education
classes, and a troubling 70% did not participate in physical education classes on a daily
basis (CDC, 2008). This lack of physical activity in school wouldn't be such a serious
issue if children were still active at home, but unfortunately that is not the case.
22
Television/Video Games/Computer Usage
Today, video games and television watching have replaced after-school play. The
YRBSS from 2007 also found that nationwide, 35% of students watched more than three
hours of television per average school day, while 25% of students played video or
computer games for more than three hours on an average school day (CDC, 2008).
Children are, unfortunately, paying the price for the hours spent with the remote and
game controllers. Data from the AddHealth project conducted by Gordon-Larsen, Adair,
and Popkin (2002) found that the odds of becoming overweight were 40%-50% higher
for youth who reported high amounts of television watching. Another large study by
Berkeyet al. (2000) discovered a direct association between television watching and
annual increases in BMI among children.
It is apparent that individually, physical inactivity and television viewing have
had a critical role in increasing childhood obesity, but there has been limited research on
the combined influence of the two. Eisenmann et al. (2008) conducted their research in
order to provide a better understanding of the complex inter-relationship between
physical activity and TV on the risk of overweight adolescence. They found that boys
and girls who reported watching less than 1 hour of television were not at an increased
risk of overweight regardless of their moderate physical activity level. However, they did
find an association between the level of moderate physical activity and risk of overweight
among adolescents who watched 4 or more hours of TV per day. Not surprisingly,
Eisenmann et al. (2008) found that the highest odds ratio was among children who had
the lowest activity levels and the highest amount oftime spent in front of the TV.
23
Snacking
Watching TV not only causes children to be inactive, but it has also been found to
increase caloric intake (Eisenmann et aI., 2008). In other words, children are not only
sitting down watching more TV, they are eating at the same time. Matheson et ai. (2004)
found that 20-25% of daily energy is consumed while watching television.
Unfortunately, fruits and vegetables are not generally the food of choice. Research has
shown that children who eat in front of the TV consume significantly fewer fruits,
vegetables, and milk than children who watch less TV, and significantly more servings of
energy-dense snack foods (Coon et aI., 2001; Temple et aI., 2007). Even more
problematic is that researchers have found that repeated occurrences of eating while
watching television may result in TV becoming a conditioned stimulus for eating, a
process commonly referred to as associative learning (Kaur et aI., 2003; Proctor et aI.,
2003; Temple et aI2007). With all of these factors considered, television watching while
snacking is not only problematic, but a major contributor to total energy imbalance.
Advertisements
Not only does television viewing disrupt habituation, it also influences children
through the use of advertisements, but unfortunately advertisements do not stop there.
They can now be found on popular children's web sites as well as many products and
characters targeted at children (Alvy & Calvert, 2008). According to the Kaiser Family
Foundation, the typical child views approximately 40,000 commercials on television each
year (2004). In 2007, this organization conducted a study that reviewed more than 1,600
hours of what children were exposed to while watching television. They were able to
translate those results into how many commercials children would be exposed to in the
24
course of one year. It was, therefore, estimated that children ages 2-7 saw 4,427 food
commercials, ages 8-12 saw approximately 7,609 food ads, and ages 13-17 were exposed
to an estimated 6,098 food-related commercials. This same study also looked at
children's exposure to public service messages regarding fitness or nutrition. The results
were quite different; the same groups of children as mentioned above were exposed to a
combined total of 369 public service announcements on fitness and/or nutrition.
Food marketing, according to the Institute of Medicine (2004), intentionally
targets children who are too young to distinguish advertising from truth, and therefore
tempts them to eat low-nutrient, high-calorie junk foods. A study conducted on TV
commercials' influences on children, found that it takes just 1- 2 exposures of a 10-to-30-
second food commercial to influence children's short-term preferences for specific food
products (Borzekowski & Robinson, 2001). Parents involved in this study confirmed that
children were influenced when reporting that their children not only requested food items
that they saw on TV, but foods in stores and restaurants as well.
What's unfortunate about these findings is that not only do commercials tend to
increase a child's desire for the advertised product, but most of the food that is advertised
is fast food, snack foods, and/or highly sugared foods (Byrd-Bredbenner & Grasso,
1999). Batada et al. (2008) found that 91 % of food advertisements that ran during
Saturday morning children's television programming were high in fat, sodium, added
sugars, or were low in nutrients. Interestingly enough, about half of those advertisements
conveyed some type of nutritional or physical activity related message.
25
Parental Involvement and Family Dynamics
Where does the responsibility of the parents fit into the overweight and obesity
equation? Ritchie and colleagues (2005) summed it up best in their article entitled,
"Family Environment and Pediatric Overweight: What is a Parent to Do?"
The role of parenting is particularly critical for young children because parents
directly determine the child's physical and social environment and indirectly
influence behaviors, habits, and attitude through socialization processes and
modeling. To the extent that overweight is a function of environment, parents of
young children may playa significant role in the prevention of childhood
overweight. (p. S70)
In the words of Ellyn Satter (2005), a dietitian and pioneer in the fight against
childhood obesity, "today's crisis is not one of childhood overweight .. .it is a crisis of
parenting and feeding" (p. 8). Because the world has changed so much in recent years,
parents are raising their children in a world that presents greater opportunities and
therefore greater challenges. According to Satter, these changes have left parents
uncertain of how to establish an "effective leadership role" when it comes to raising their
children (p. 7). Ifthere is any truth to Satter's statements, then we may be faced with an
even larger predicament than originally anticipated. Ritchie et al. (2005), as previously
mentioned, stated that parents "are indisputably the first line of prevention" for our youth,
and it has become evident that today's children need his or her parents to be leaders now
more than ever (p. S73).
Are parent's to blame for the increase in childhood obesity? According to Brad
King (2007), an author and nutritional researcher, the answer to that questions is yes. In
26
his artic1eentitiled Aiming the Blame, King asks the simple, yet forward, questions such
as, "who finally gives in to the screams and tantrums that develop from the 'I gotta have
it now' attitudes" and "when was the last time you saw a child paying for groceries" (p.
36)? While Mr. King's statements may seem somewhat rash, the truth is that
traditionally it is the parent's responsibility for buying the family's food, Wake et. al
(2007) found that parents, particularly fathers, who use a low level of control were more
likely to have an overweight or obese child. Studies have continually found that when
parents choose a more balanced style of parenting, such as authoritative, over a loose or
controlling style they have better success at maintaining a healthier environment and
therefore better weight outcomes for their child (Golan & Crow, 2004; St. Jeor et aI.,
2002; Wake et aI., 2007). While it may be more conveient to give in to the constant
nagging short-term, we need to take a good, hard look at the long-term effects of parents
giving in time and time again.
Parental influence on children's eating habits has been studied extensively over
the years, and it has become apparent that it does in fact influence a child's weight status
(Wardle, Carnell, & Cooke, 2005). Parents not only determine what foods are made
available, they also decide how it is prepared and how much is served. What may not be
as obvious, is the parent's own eating habits and how it effects their children.
Parental modeling is not only important when it comes to fruit and vegetable
intake; what is also important to consider is how the parents view themselves. Stice,
Agras, and Hammer (1999), found that maternal body dissatisfaction, internalization of
the thin-ideal, dieting, bulimic symptoms, and maternal and paternal body mass was
related to the surfacing of childhood eating disturbances even at a very young age. In
27
addition, parents who use food for emotional reasons, whether it be for themselves or to
soothe or distract a child, influence their children to eat for emotional reasons rather than
for hunger. In a study of 428 families, researchers found a positive relationship between
parents' emotional eating and adolescents' emotional eating (Snoek et aI., 2007). These
findings are yet another reason why parents are so crucial to the intervention process,
because if parents are unaware of their own negative perceptions, one cannot expect their
child to change theirs.
Feeding Behaviors
When it comes to food, however, not only do we need to be concerned with what
parents feed their children, but we also need to consider how they feed them. While
Ellyn Satter (2005) agrees that what a parent feeds their child is important for nutritional
health, she states that child weight problems are behavioral problems, and that behavior
problems cannot be solved by focusing on food selection. For this reason, it is important
to focus on feeding behaviors of parents who are concerned with his or her child's
weight.
Restrictive feeding is a practice that parents may unconsciously or consciously
employ in attempt to prevent their child from becoming overweight. However, this
strategy has been found to actually worsen a child's weight control problem (Faith et aI.,
2004). By controlling a child's intake, parent's are unknowning undermining their
child's abiltiy to self regulate, and therefore the child's ability to grow consistently
(Satter, 2005). Even at a young age of 6 months, researchers found that parental control,
specifically maternal control, had an effect on a infant's ability to regulate their own
intake (Farrow & Blissett, 2006). More specifically, when maternal control was low to
28
moderate, infants with early rapid weight gain showed decelerated growth within the first
year. When maternal control was high, however, infant's were unable to regulate, and
therefore maintained a constant weight gain. Restrictive eating not only interferes with a
child's internal cues for hunger and satiety, but it may also contribute to long term effects
such as; disinhibited eating, eating in the absence of hunger, food refusal, and eventually
childhood overweight and/or obesity (Birch, Fisher, & Davison, 2003; Carper, Fisher, &
Birch, 2000).
While restrictive feeding has been found to be counterproductive, unpredictable
feeding can have negative reprocussions as well. Unpredictable feeding as defined by
Ellyn Satter (2005), occurs when parents are overly casual about providing family meals
and snacks. This type of feeding has the ability to make a child become preoccupied with
food due to the uncertainty of the next meal. This uncertaintly, therefore, has the
potential to cause many children to overeat when food is finally served. According to
Satter, "even the most reprehensible family meal is better than no meal at all" (p. 32).
Family Meals
Children need structure and one of the easiest ways for parents to provide it is
though family meals. Unfortunately, the trend for meal consumption has migrated out of
the homes and into restaurant establishments. In their study of 802 adolescents from four
major cities, Zoumas-Morse et al. (2001) found that the calorie content of restaurant
meals consumed was 55% higher than meals consumed at home. They also found that
when children and adults ate out they consumed more fat, more fried foods, more soft
drinks and not surprisingly, less fruits and vegetables.
29
Intervention Factors
Adolescence is marked by a significant transitional period in a child's life. This
transition, if not taken advantage of, can result in a decrease in diet quality and level of
physical activity (Nelson et aI., 2006). There have been a multitude of intervention
strategies, most of which incorporate some level of nutrition education. By providing
nutrition education, it is the intent that knowledge will increase and filter into other areas
such as healthier eating behaviors and attitudes.
An intervention conducted in three public schools in Chicago, Illinois consisted of
monthly sessions of nutrition education over the course of a school year, and the results
were promising. Researchers were able to determine that by providing nutrition
education children experienced significant improvements in regards to nutrition
knowledge. Improvements were also seen in behavior and intentions, but even more
promising is that these improvements were translated into reductions in BMI and waist
circumference (Monty, Handu, & Chmel, 2008).
Nelson et aI. (2009), assessed adolescents' knowledge, and how it relates to
energy intake and expenditure. Their findings indicate that adolescents do in fact lack
knowledge on a wide range of basic concepts. More specifically, adolescents' knowledge
was not associated with sweetened beverage consumption, fast food intake, weight status,
and/or body composition. The study also assessed parental knowledge, and found that
overall parental knowledge is a significant predictor of adolescent knowledge.
Unfortunately, this was not the case in regards to the responses on individual items,
which may be an indication of a communication barrier between parents and children.
30
Jennifer O'Dea (2003), a professor in the department of education as well as a
Registered Dietitian, conducted research to find out why kids eat healthy foods and the
barriers that prevented them from doing so. The results highlighted a resonating theme
that kids just eat what is available. More importantly, O'Dea found that children of all
ages expressed the need for their parents to "encourage, support, and enable them to be
involved in more healthful behaviors" (p. 500).
This finding along with the research presented thus far is evidence that parents
playa crucial role in their children's wellbeing. It also supports that there is a dire need
for improving the knowledge, behavior, and attitudes/intentions among parents and their
children.
31
Chapter Three: Methodology
This chapter will include information regarding how the sample was collected, a
description of the sample, and the instrument that was used. In addition, data collection
and data analysis procedures will be given. The chapter will conclude with the
methodological limitations.
Subject Selection and Description
Prior to the study's inception, approval was granted through UW-Stout's
Institutional Review Board. (Appendix A). To begin the study, informational fliers were
sent to families with a child between the ages of eight and ten years old who attended a
public grade school in Dunn County (Appendix B). Families interested in participating in
the program, were then instructed to contact Jan Pejsa at the Red Cedar Medical Center
or their child's school counselor or teacher for additional program information (Appendix
C). The contact personnel were to obtain names and addresses of interested families, so
additional program information could be sent. The packet contained a program
application as well as an Informed Consent Form (Appendix D) for. the families to fill out
and return to Jan Pejsa. Of the received applications, twenty families were to be selected
at random to participate in the program. However, due to low response, all of the
families who filled out the required paperwork were included in the intervention program
and hence, this study.
Instrumentation
In order to determine the dietary patterns of the participants, Hearts N' Parks
questionnaires were implemented. Hearts N' Parks is a national, community-based
program that is supported by the National Heart, Lung, and Blood Institute (NHLBI) of
32
the National Institutes of Health (NIH) and the National Recreation and Parks
Association (NRPA) (NHLBI, n. d.). The program was designed to aid park and
recreation programs encouragement of heart-healthy lifestyles. The survey portion was
developed to evaluate the program and was found to be an effective method to evaluate
participant's knowledge, behaviors, and intention. Three different sets of questionnaires
were used in order to target the appropriate age group (children, adolescents, and
parents). For this particular study only the child and parent questionnaires were utilized.
The children's questionnaire (Appendix F), which was designed for children
under the age of eleven, was largely derived by Hearts N' Parks from the Child and
Adolescent Trial for Cardiovascular Health (CATCH) instruments (NRP A, 2004). The
questionnaire is picture based and is broken down into three heart healthy sections. The
first section is directed towards eating knowledge. The question asks "Which food is
better for your health?" and children are to choose between two food items by circling the
one they believed to be the healthiest. The second heart healthy section focuses on
behavior by asking "What foods do you eat most of the time?" The last heart healthy
section deals with the child's intentions. This section asked "What would you do?"
Examples of these choices are "eat food without adding salt" or "shake salt on the food
before eating." These sections contain seven questions each and are scored by the
number of questions answered correctly.
The children's questionnaire also contains sections on physical activity. This
portion is divided into two sections; physical activity attitude and "things I[the child] like
and things I do". The physical activity portion of the questionnaires was not utilized,
however, as it was not the focus of this particular study.
33
The parent questionnaires (Appendix G) are also age-appropriate, and were
developed from an accumulation of several instruments that were refined for Hearts N'
Parks (NRP A, 2004). The first series of questions asks the respondent's gender, age
group, race, and education level, which is followed by twelve remaining sections.
The first section is a series of six multiple-choice questions focusing on heart
healthy eating knowledge. The second section is a series of nine true/false questions
pertaining to the respondent's knowledge of overweight/obesity risks. The scores from
the first two sections represent the number of correct answers.
Heart healthy eating attitude is the third section and is made up of six questions.
This section is somewhat different in that it is based on a 4-point importance scale
("very," "somewhat," "not too," or "not at all important"). Respondents are to indicate
how important each of the six healthy eating habits are to him/her. The scores from this
section are an average of all six questions, with four being the best possible score.
Overweight/Obesity attitude is the fourth section. This section is based on eight
questions on a 4-point agree/disagree scale. The purpose ofthis section is to determine
the respondent's predisposition for overweight/obesity. The healthiest attitude in regards
to achieving a healthy weight was represented by a score of 4.
Section five focuses on heart healthy eating behaviors. Respondents answered
seven questions that measure the frequency of how often the adult makes healthy eating
choices. This series is formatted in a 0-4-point scale, with 0 translating into "never" and 4
meaning "almost always."
The remaining sections of the parent questionnaire are not of importance to this
particular research project, and therefore will not be described in detail. However, they
34
included questions regarding; physical activity level, physical activity attitude, physical
activity knowledge, high blood pressure knowledge, cholesterol knowledge, an overall
FIT score, which is a total ofthe number of hours the adult engaged in 14 different types
of physical activity over the previous seven days, and finally an overall SIT score, which
measured the number of inactive hours for various activities in the last seven days.
Data Collection Procedures
Data was collected between the months of April and May of 2007. Confidentiality
was obtained through the assignment of numeric codes. Each respondent was assigned
such a code and given the corresponding questionnaire. The questionnaires were
distributed during the first session. Families were divided into three groups (children,
adolescents, and parents) prior to taking the survey in order to minimize any interference
or influence from other family members. Members of the intervention team were
available to assist if any of the respondents had any questions. Each group was instructed
to tum over his or her survey upon completion. Surveys were then collected by
intervention team members and given to the program director.
Families participated in various activities throughout the ten sessions. Each
session began with a meal that emphasized and encouraged interaction between parent
and child. The majority of the sessions consisted of a nutrition education component and
a physical activity component; while others were led by guest speakers.
Data Analysis
Data obtained from the questionnaires was analyzed with the assistance of Susan
Greene, research and statistical consultant for the University of Wisconsin Stout, through
the use of a computerized statistics package entitled, Statistical Program for Social
Sciences, version 14.0 (SPSS).
35
Descriptive analysis (mean, median, mode, standard deviation, standard error,
minimum and maximum ranges) were run in order to profile the demographics and to
gather information regarding the total scores obtained from the child and parent
questionnaires. Frequencies were also run on child and parent demographics as well as
each individual section of questions. Analysis of the questionnaires included a scoring
component as the survey was divided into sections and scored according to the answer
key provided by the Hearts N' Parks program.
Pearson correlation coefficients were analyzed to determine if any relationships
existed between a child's nutrition knowledge, behavior, and intentions, a parent's
knowledge, behavior, and attitude, as well as any correlations between parent and child.
Limitations
One major limitation to the study was the number of participants. The goal was to
obtain 20 families, but unfortunately the goal was not met. Out of all of the families who
showed interest in the intervention, thirteen followed through and attended the first
session. This may have been due in large part to the method of distribution. This research
project focuses on preliminary data: post test data could not be analyzed as there was a
significant drop off in participation throughout the intervention. However, higher
participation would have allowed for more reliable data as well as a more representative
depiction of the families in Dunn County.
Another limiting factor to consider is the fact that this was a new project and the
first of its kind to be implemented in the community. This may have affected people's
36
perception and willingness to participate in an unknown, unproven intervention on a very
sensitive subject. Another concept to consider is the community'S awareness of
childhood overweight and obesity as a major health threat. Ifparents were unaware of
their child's weight status, they may not have thought it necessary to participate in such a
program. Parents of overweight or obese children may also have been unaware of the
related complications and health risks, and therefore not realized the importance of
preventing further childhood weight gain.
37
Chapter IV: Results
This chapter will include demographics from the study participants along with
item analysis. The remainder of the chapter will summarize the findings in relation to the
identified research objective.
Demographic Information
The study consisted of thirteen families, with children between the ages of 6-10
years of age, who resided in Dunn County. The child population consisted of 35% (n=6)
boys and 65% (n=ll) girls. Each age group was uniformly represented with 35% (n=6) of
the children being between the ages of 6-7 years old, 35% (n=6) were 8-9 years old, and
29% (n=5) were between the ages of 10-11 years. Participating parents were made up of
5% (n=l) males and 95% (n=18) females. 74% (n=14) were between the ages of31-40
years, while 26% (n=5) were between the ages of 41-50 years. 95% (n=18) of the
participants identified themselves as white/Caucasian, while the other 5% (n=l) selected
the "other" category. In regards to the education level of the parents, 42% (n=8) had a
college degree, 37% (n=7) had some college experience, while the remaining 21 % (n=4)
classified themselves as having a high school degree.
Research Objectives
What are the total scores of children's nutritional knowledge, behavior, and intentions?
In order to determine if any correlations exist between these three factors, total
scores were calculated. All three categories were made up of 7 questions each. One
point was given for each correct answer, which resulted in a possible 7 points for each
section. As shown in Figure 1, the mean for the total nutrition knowledge score was 5.9
with a standard deviation of ± 0.29, 4.3 ± 0.47 for total nutrition behavior score, and 4.7 ±
38
0.44 for total nutrition intention score. Figure 2 represents the number of questions
answered correctly in each of these sections.
Figure l
Tolal nutrition. scores /01' children 's knowledge, behavior, anci intention
7
6 ;E
QI 5 -0 v T ... VI c 4 .2 ·E ~
" 3 z
...
Ir .. . ~
{2 2 H .
..
1
Ii 0 I' .
Knowledge Behavior Intention
Figure 2
Number o/nutrition questions answered correctly
10
'" 9 QI VI 8 " 0 c. 7 VI QI 6 cr: ..... 0 5 ?;
4
" QI 3 QI
• Knowledge
• Behavior
:::I a 2 QI
In tention
~ ... 1
0
o 1 2 3 4 5 6 7
Number of Healthy Choices Selected
39
Do any correlations exist between a child's nutritional knowledge, behavior, and/or
intentions?
In order to determine if relationships were present, a Pearson r (2-tailed)
correlation test was run at a p-value of 0.05. Data collected for 17 children showed no
significant relationships between a child's nutritional knowledge and intentions (R=
0.306, p= 0.233) and between a child's knowledge and their behavior (R= 0.144, p=
0.580). However, and not all that surprising, the relationship between a child's behavior
and intentions was found to be positively, statistically significant (R= 0.844, p=O.OOO)
(Figure 3).
Figure 3
Correlation between children's healthy eating behavior and intentions
8 OJ 10..
0 7 u
V') 6 c:
0 5 ',i:i
c: OJ 4 ..... c:
3 c:
A
A A ~ '" ~ '"
A
A • ~ 'o/Y
~ A .. - '" V
,2 2 ..... A. • y • 'i: ..... :s 1
Z 0 I I I I
o 2 4 6 8
Nutrition Behavior Score
40
What are the total scores of the parents' knowledge, behavior, and attitudes?
The parent questionnaire was similar to the children's in respect to nutrition
knowledge, behavior, and attitude. However, it also assessed the parents' knowledge and
attitude in relation to overweight/obesity. Out of a maximum 6 points for nutrition
knowledge, parents' scored a mean of3.6 ± 0.2, 18 ± 0.5 for eating behavior, which was
out of a total of 28 points, and a mean of 19.2 ± 0.4 for healthy eating attitude out of a
possible 24 points. Figure 4 represents the average scores for each ofthese categories as
a percentage of total possible points along with the standard error for each category. In
terms of overweight/obesity knowledge, parents scored an average of 6.1 ± 0.2 with 9
being the maximum score, and out of a possible 32 points parents scored a mean of 22.1
± 0.8 for the overweight/obesity attitude category. Figure 5 represents the average scores
for these two categories as percentages of the total possible points as well as the standard
error for each.
41
Figure 4
Tota/nutrition scores of parents ' healthy eating knowledge. behavior. and attiludes
100
90
'" 80 -0 u
'" 70 E :J E 60 "x '" E 50 -0
'" 40 01)
'"
± , i: , " :f: rj~ ~ "
I.·· : " r;
• Knowledge
• Attitude
Behavior -" 30 '" u -'" 20 0-
lD
( . ;::.: i> [1
; .4 Hi] , :;.
0 Nutrition
Figure 5
Tota/nutrition scores of parents' overweight/obesity knowledge and attitudes
100
90
'" 80 '" -0 u 70 '" E -c :J 60 E "x '" 50 E - ! " • Knowledge 0
'" 40 01)
'" I '
• Attitude -" 30 '" ,
u -'" 20 0-
10 ; ~" " r" .
0 , .
Overweight/Obesity
42
When reviewing the parents' individual scores for nutrition knowledge, it was
found that approximately 74% of the parents answered four or five of the six total
questions correctly. Out of a possible 28 points for healthy eating behavior, the highest
score obtained was 21 while the lowest was 12. When determining the parents'
nutritional attitude, approximately 84% of respondents claimed that healthy eating was at
least somewhat or very important to them.
In terms of individual scores for overweight/obesity knowledge, 63% of the
parents answered six or less of the questions correctly out of a possible 9 points. Only 1
parent answered eight correctly and no one got all nine correct. Overweight/obesity
attitude had somewhat better results. Eight of the 19 parents scored between 24-28 points
out of a total 32, which indicates that they disagreed with the unhealthy statements at
least most of the time.
Are any correlations present between a parent's nutritional knowledge, behavior, and/or
attitude?
Pearson r (2-tailed) correlation tests were run in order to determine if any
relationships were present. Data from 19 parents was included in this data set. The table
below indicates whether the relationship was significant (S) or not significant (NS). It
also provides the correlation value (R).
43
Table I
Correlations present between parent data
PA PB Ov/Ob K Ov/Ob A Total K' Total A"
Solo. NS NS NS NS PK
R* -O.602 R= -0.083 R= 0.35 1 R= 0. 125 R= -0.1 84
NS NS NS NS PA
R=0. 122 R= -0.1 16 R= -0.292 R= -0.446
NS NS NS S· PB
R= -0.026 R= 0.423 R= -0.067 R- O.495
Solo Solo. Ov/ObK
R- -O.539 R- -O.610
NS Ov/Ob A
R= -0.240
S· Total K'
R- -O.47S
AbbrevIatIOns used In thIs table: P (parent). K (knowledge). A (attItude). B (behaVIor).
Ov/Ob (overweight/obese)
Highl ighted cells represent where data is sign ificantly different
• Correlation is sign ifi cant at the p < 0.05 level (2-tailed)
•• Correlation is significant at the p < 0.01 level (2-tailed)
a= total knowledge regarding nutri tion and obesity
b = total attitude regarding healthy eating and obesity
Does a child's knowledge, behavior, and/or intentions emulate his/her parents'
knowledge, behavior, and/or attitude in regards to dietary practices and beliefs?
44
Research objective 3 is of particular importance because it provides insight into
the level of parental influence on his or her child. The first set of variables looked at
possible relationships between a child's nutrition knowledge to that of the parent's
knowledge, behavior, and attitude. Although no statistical significant correlations were
found amongst this data set, there was one point of interest worthy of mention, which was
between the parent's and the child's nutrition knowledge. A medium correlation was
present between the two factors, however, this relationship was found to be negative (R=
-0.302, p= 0.224).
The next set of variables examined a child's behavior in relation to parents'
knowledge, behavior, and attitude, and while no significant correlations were present,
results were interesting nonetheless. Both sets of data were very small in terms of
correlations; however, the fact that the results were negative is of importance. A parent's
nutrition knowledge (R= -0.286, p= 0.301) and total nutrition and obesity knowledge (R=
-0.268, p=0.334) were both negative in relation to child's behavior.
Lastly, the results obtained from evaluating a child's intentions to that of a
parent's knowledge, behavior, and attitude also created points of interest. Analysis
revealed a small, but not statistically significant, negative correlation (R= -0.380, p=
0.163) between the parents' nutrition knowledge and the child's intentions. Similar
findings were found amongst parent's overweight/obesity knowledge and a child's
intentions. While a non-significant correlation between the two was present, that
relationship was also negative (R= -0.436, p= 0.105). The combination of parents'
45
knowledge in tel1l1S of nutrition and overweight/obesity was found to have a slightly
stronger negative correlation to a child's intentions, however, this too was found to be
negative (R= -0.484, p= 0.484). Table 2 represents these relationships with the
highlighted sections indicating relationships that were of negative correlation.
Table 2
Relationships between parents alld children
PK PB PA O/OvK O/OvA Total K Total A
CK R- ·O.302 R= 0.279 R= 0.00 R= 0.00 R= 0.126 R-·0.163 R= 0.123
P - O.244 p= 0.263 p= 1.00 P= 1.00 P= 0.619 P-0.519 P= 0.628
CB R- ·O.286 R- ·0.212 R- 0.129 R- ·0.172 R- -0.195 :a.--O.268 R-·0.165
P-0.301 P-0.447 P= 0.646 P-0.541 P-0.485 P-O.334 P- 0.558 . ,
C[ R- -O.308 I H--0.027 R= 0,08 1 :a.- -O.436 R= 0.212 :a.- -O.484 R- 0.241
P-0.163 P-0.924 P= 0.775 P- 0.105 P= 0.448 P-0.068 P= 0.387
Hlghhghted sectIOns slgmfy negallve relationships
Abbreviations used in this tab le: P (parent), C (children), K (knowledge), B (behavior), I
(intentions), A (attitude), Ov/Ob (overweight/obese)
46
Chapter V: Discussion
This chapter contains limitations of the study as well as a discussion of the
pertinent findings. It will conclude with recommendations for future interventions in
order to reduce the occurrence of childhood obesity in our communities.
Limitations
A limitation that had a significant impact on the outcome of the primary purpose
of the project was the small sample size. Due to the high dropout rate, post-test data was
not able to be analyzed, and therefore made it impossible to determine the outcomes of
the intervention in relation to the parents' and children's knowledge, behavior, and
intentions/attitudes. Perhaps more lead time and/or preparation would have provided
ample time to recruit the number of families intended for the study. The high dropout
rate may have been due to commitment requirements. Due to the study's small time
frame for execution (dependent on the grant funding period), participants were asked to
attend two sessions a week for several weeks. This may have been difficult for some
families as they had a significant drive time of 40 minutes or more.
Another limitation that may have hindered the study was perhaps the sensitivity of
the topic: childhood obesity. This may have affected recruitment efforts in that recruiters
may have felt hesitant in referring families. It may also have made parents tentative to
want to participate due to the fear of how the child might react. Parents may have also
been tentative to participate if they were overweight themselves or felt that they would be
blamed for their child's weight.
47
Conclusions
The first set of objectives ofthis study was to determine if correlations were
present between a child's nutrition knowledge, behavior, and intentions. Before
examining these relationships, it is important to discuss the children's scores in these
categories individually. In terms of nutrition knowledge, of the 17 children examined,
82.3% answered six or more of the questions correctly. This is an indication that
children, for the most part, are aware of which foods are better for their health. \
When looking at behavior, the results were not as promising. Only 35% of the
children answered six or more of the questions indicating healthy eating behavior. Of the
remaining 65%, 47% of the children selected only two or three of the healthy choices.
These results provide insight to the fact that when presented with two options, healthy
versus not healthy, the majority of children are not choosing the healthier option.
Do the children have good intentions when it comes to making healthy choices?
The results indicate a slight improvement over behavior in that 47% of the children chose
six or more of the healthy options. Approximately 30% of the children answered three or
less of the questions correctly, indicating that this group of children did not necessarily
want to eat healthier foods.
Correlations of Children's Variables
The first obj ective of this study was to determine if correlations existed between a
child's nutrition knowledge, behavior, and intentions. While most of the children's
correlations were insignificant and small in size, the correlation between a child's
behavior and intentions was strong and statistically significant. This is an indication that
a child's intentions heavily influence the types of food that the child eats most of the
48
time. This is a promising finding for several reasons. The first being that if the child has
healthy eating intentions it will most likely translate into them making healthier food
choices. It appears that children in this population experience few barriers that prevent
them from acting on their intentions. However, researchers have found that intentions
may not necessarily be a reliable determinant of a child's eating behavior (Burgess
Champoux et aI., 2008). Another reason this finding may be of importance is that it may
shed light on how increased knowledge could indirectly increase a child's healthy eating
behaviors. Although the relationship between knowledge and behavior was small and not
significant, the fact that knowledge and intentions had a positive relationship along with
intentions and behavior being strongly correlated may indicate that by increasing a
child's knowledge one may inadvertently increase the child's likelihood of eating
healthier foods. Research has shown, however, that providing nutrition education alone
does not always translate into improved behavioral outcomes (Kirk, Scott, & Daniels,
2005; Nelson, Lytle, & Pasch, 2009).
Correlations of Parents' Variables
The second objective was to determine whether any relationships existed between
the parents' nutrition knowledge, behavior, and attitude. When reviewing the individual
scores of nutrition knowledge, parents answered most ofthe questions correctly. In terms
of behavior, while none of the participants chose the healthier option all of the time, the
majority of them chose a healthier option at least some of the time. Nearly 90% ofthe
parents surveyed felt that healthy eating was at least somewhat or very important to them,
which indicates a relatively positive attitude towards nutrition. As for overweight/obesity
knowledge, over half of the parents' answered six or less of the questions correctly,
indicating a fairly low level of knowledge in this area. The opposite was true for
overweight/obesity attitude; however, as their attitude was, in general, positive.
49
As for possible correlations between the parents' variables, one would assume
that as nutrition knowledge increased so too would a parents' healthy eating attitude.
However, a negative and significant relationship was found between these two variables.
The same relationship was found between overweight/obesity knowledge and attitude.
When combining total knowledge scores and measuring them against total attitude
scores, a negative and statistically significant relationship was also found. While the
results from this study are somewhat discouraging, research has shown that when parents
were presented with weight-related lifestyle practices, they perceived them as relevant
and a potential motivating factor when contemplating behavior changes (Kubik, 2008).
Many assumptions could be made about these findings; however, at first glance it
may appear that the less people know about healthy eating practices and
overweight/obesity, the less worried they are about making unhealthy choices and
gaining excess weight. This assumption may fall in line with the old saying, "ignorance
is bliss." There may also be a level of frustration that parents experience, whether it is
with their own health and/or weight or that of their children's. According to Ritchie et al
(2005), even some of the most well-meaning and informed parents will fail in their
efforts to provide a healthy lifestyle for themselves and their children, because there are
so many factors that come into play on a daily basis.
The last set of variables was measured against the total attitude scores obtained
from combining healthy eating attitude and overweight/obesity attitude. A positive and
significant relationship was found between healthy eating behavior and total attitude.
50
This finding suggests that as one's healthy eating behavior improves so too will their
overall attitude and vice versa. This is an important finding because a person's attitude
has great potential to help behavior changes become permanent fixtures in one's life.
Correlation between Parent's and Children's Variables
Another goal of this study was to determine the level of influence that a parent
has on his or her child. While the results were somewhat unexpected, they were
nevertheless interesting. No significant correlations existed; however, it was surprising
to discover the number of negative correlations. These were observed between the
child's knowledge and the parents' nutrition knowledge and total knowledge. Negative
correlations were also found among a child's intentions and the parents' knowledge,
behavior, overweight/obesity knowledge, and total knowledge. The only positive
correlation found among children's behavior was with parents' attitude. Interestingly,
parents' nutrition attitude was the only correlation that was positive with all three child
factors (knowledge, behavior, and intentions). However, it is important to acknowledge
the small size of the strength in all of these correlations, and therefore observations
should be taken lightly.
Perhaps the most important goal of family-based interventions is to improve
children's eating behaviors. By including the parents in the intervention process one
would hope that the parents would influence their children enough to bring about
behavior changes. For one reason or another, a parent's increased knowledge is not
translating into the child's behavioral response. This is definitely an area of concern, but
even more so is the fact that no relationship was present between parental behavior and
children's behavior. This is an interesting finding because research has consistently
51
shown that children learn behaviors from the individuals who control the majority ofthe
rewards and punishments (St. Jeor et aI., 2002). While the results obtained may be
somewhat discouraging, it is important to remember that children still rely on his or her
parents to provide encouragement and support, and need their parents to help them be
involved in more healthful behaviors (O'Dea, 2003).
One possible explanation for these findings could be that schools tend to playa
larger part in providing nutrition education, and therefore children do not generally rely
on his or her parent's for this type of information. If this is true, then as schools lose
funding and nutrition education courses are cut, parents will need to assume the role of
teaching their children the importance of healthy eating.
Another potential explanation is that children tend to resist change, and do so by
rebelling. According to Kahn (1982), it is normal for children to experience increased
rebelliousness and defiance during certain periods of their development. In order to help
parents through these trying times, this would be an important concept to include in the
intervention process.
It is also possible that the questionnaires used were not as effective as hoped in
assessing the knowledge, behavior, and attitudes of the parents and children. Revising
the assessment tool to better reflect the study would be an added benefit. While the
Hearts N' Parks questionnaires provided valuable information, refining the questions to
better reflect the study may have assisted in finding more concise data. Several of the
sections asked a series of six questions, which may not have been sufficient enough to
determine the participants true nutrition knowledge, behavior, and/or attitude. Several of
the questions were also simplistic in nature, which may have made it easier for
52
participants to select the correct answer. Perhaps having additional questions in each
section as well as more thorough questions would provide for a more accurate depiction
ofthe participants true knowledge, behavior and attitude.
Recommendations
In regards to this study, there are several recommendations that could benefit
future participants as well as the overall outcomes of family-based interventions in
general. First and foremost, interventions need to be tailored to the individual child and
his or her family. They also need to assess the family's readiness to make lifestyle
changes as well as evaluate their stage of cognitive and psychosocial development (Kirk,
Scott, & Daniels, 2005).
With all the research on childhood obesity, it has become apparent that parents
playa critical role, and therefore need to be included in the intervention process. Golan
and Crow (2004) would agree. In their study they looked at the long-term changes in the
child's weight following a family-based intervention that focused only on the parents and
one that targeted just the child. They found that children in the parent-only group had a
significantly higher reduction in percent overweight than did the children in the child
only group. Even more promising is that at the 7-year follow-up 60% of the children in
the parent-only group had reached a non-obese status while only 31 % reached that level
in the child-only group.
This study and others demonstrates the importance of including the parents in the
intervention process. There is no denying that parents are the primary mediators of
change, and therefore according to St. Jeor et al. (2002) family-based interventions are
the appropriate mode of treatment. In fact, researchers have found a significant
53
correlation between changes in parent and child z-BMI, indicating that a change in the
parent's z-BMI is a strong predictor of a change in the child's z-BMI (Wrotniak et aI.,
2004).
For many families faced with the dilemma of childhood obesity, implementing
behavior modification needs to be addressed at every level with each family dynamic
examined. Providing nutrition education alone, to increase knowledge and hopefully
change behavior, does not always work as research has shown (Kirk, Scott, & Daniels,
2005; Nelson, Lytle, & Pasch, 2009). In order for interventions to be truly effective on
changing behavior, research indicates that programs should include a combination of
goal-setting, self monitoring, stimulus control, and incentives within the context of a
supportive family environment (Kirk, Scott, & Daniels, 2005; Schwartz & Brownell,
2007; St. Jeor et aI., 2002).
Because the home environment has potential for affecting the outcomes of an
intervention it needs to be strongly addressed (Schwartz & Brownell, 2007). In fact,
research has shown that modification of the shared-family environment may not only
have positive effects on the parents' weight, but the child's weight as well (Wrotniak et
aI.,2004). In order to maximize the responsibility of parents and children when trying to
achieve and maintain healthy practices, they need to have an environment that supports it.
This means limiting screen time, increasing physical activity, providing nutritious foods,
and limiting foods that are high in fat and/or sugar. It is very important to encourage and
provide parents with the tools needed in order to manage their home environment as well
as prevail over the external influences that may undermine their efforts.
54
By implementing parenting techniques, proper feeding practices, and
environmental restructuring, parents may be more motivated to make bigger changes in
the home than if they were not the targets of the intervention according to Wrotniak et aI.
(2004). Not only that, it would provide the parents with an opportunity to be positive role
models for their children. It has been found that parents who have good dietary
awareness and practices are more likely to make healthier food choices for their children
(Clark et aI., 2006; Wardle, Carnell, & Cooke, 2005).
Parents can improve their home environment and positively influence their
children's dietary habits simply by providing family mealtimes. Having more meals at
home is not only positively associated with dietary intake, but is also related to other
healthful behaviors among adolescents (Cason, 2006; Larson et aI., 2007).
While research has found that meals consumed at home are often of better
nutritional quality and establish healthful behaviors later in life, what most do not
consider is the concept of togetherness. Fulkerson et aI. (2008) found that what parents
enjoyed most about family meals was the togetherness they experienced while eating,
relaxing, and laughing as a family. Family meals not only increase the likelihood of
higher dietary quality, but they also facilitate opportunities for parental modeling, family
interaction, communication, and above all a sense of unity (Cason, 2006; Larson et aI.,
2007). The goal for interventions in terms of family meals should therefore be to make
family meals a priority again and to make them part of the family's traditions (Ikeda,
2007; Fulkerson, Neumark-Sztainer, & Story, 2006).
Many remedies have been proposed and attempted in the fight against childhood
overweight and obesity. Efforts have extended into the communities, schools, and even
55
government, but where we need to see the most effort is in the homes. Healthy habits
begin at the beginning of life and need to be maintained over that lifetime. As long as
parents or guardians choose to provide their children a healthy environment to grow, we
have a fighting chance. It is the responsibility of health professionals, however, to
provide parents with the tools needed in order to raise healthy, happy children, and
research has shown that the best way to accomplish this is through the use of fami1y
based interventions.
56
References
Alvy, L., & Calvert, S. (2008). Food marketing on popular children's web site: A content
analysis. Journal of the American Dietetic Association, 1 08(4), 710-713.
Retrieved December 22, 2008 from:
http://download.journals.elsevierhealth.comlpdfs/journals/O002-
82231PIIS0002822308000072.pdf
American Heart Association. (2009). Heart disease & stroke statistics. Retrieved April
19,2009, from:
http://www.americanheart.org/downloadable/heart/123783441267009Heart%20an
d%20Stroke%20Update.pdf
Baker, J., Olsen, L., & Sorensen, T. (2007). Childhood body-mass index and the
risk of coronary heart disease in adulthood. New England Journal of Medicine,
357(23),2329-2337. Retrieved December 11, 2007, from:
http://content.nejm.org/cgi/reprint/357/2312329.pdf
Batada, A., Seitz, M., Wootan, M., & Story, M. (2008, April). Nine out of 10 food
advertisements shown during Saturday morning children's television
programming are for foods high in fat, sodium, or added sugars, or low in
nutrients. Journal of the American Dietetic Association, 1 08(4), 673-678.
Berkey et al. (2000). Activity, dietary intake, and weight changes in a longitudinal
study of preadolescent and adolescent boys and girls. Pediatrics, 105(4), 1-9.
Retrieved October 4, 2008, from:
http://pediatrics.aappublications.org/cgi/reprintIl05/4/e56
Birch, L., Fisher, J., & Davison K. (2003). Learning to overeat: maternal use of restrictive
57
feeding practices promotes girls' eating in the absence of hunger. American
Journal of Clinical Nutrition, 78(2),215-220. Retrieved December 1, 2008, from:
http://www.ajcn.org/cgi/reprint178121215
Bray, G., & Champagne, C. (2005). Beyond energy balance: there is more to
obesity than kilocalories. Journal of the American Dietetic Association, 105(5),
S17-S20. Retrieved June 4,2008, from:
http://download.joumals.elsevierhealth.comlpdfs/joumals/0002-
82231PIIS0002822305002038.pdf
Borzekowski D., & Robinson T. (2001). The 30-second effect: an experiment
revealing the impact of television commercials on food preferences of
preschoolers. Journal of the American Dietetic Association, 101 (1), 42-46.
Retrieved October 8, 2008, from:
http://download.joumals.elsevierhealth.comlpdfs/joumals/O002-
82231PIIS0002822301000128.pdf
Burgess-Champoux, T., Rosen, R., Marquart, L., & Reicks, M. (2008, April). The
development of psychosocial measures for whole-grain intake among children
and their parents. Journal of the American Dietetic Association, 1 08(4), 714-717.
Byrd-Bredbenner C., & Grasso D. (1999). Prime-time health: an analysis of
health content in television commercials broadcast during programs viewed
heavily by children. International Journal of Health Education, 2, 159-169.
Retrieved October 8, 2008, from:
http://www .kittle.siu. edU/iejhe/paid/1999/number4/pdf/byrd. pdf
Carper, J., Fisher, J., & Birch, L. (2000). Young girls' emerging dietary restraint and
58
disinhibition are related to parental control in child feeding. Appetite, 35(3), 121-
129. Retrieved December 1, 2008, from: www.sciencedirect.comlscience?_ob
Cason, K. (2006). Family meals: More than just eating together. Journal of the American
Dietetic Association, 106(4),532-533. Retrieved December 23,2008, from:
http://download.joumals.elsevierhealth.comlpdfs/j oumals/0002-
8223/PIIS0002822306000 125 .pdf
Centers for Disease Control and Prevention. (2007). National diabetes fact sheet.
[Electronic Version], Retrieved November 15, 2008, from:
http://www .cdc. gov / diabetes/pubs/pdf/ndfs _2007. pdf
Centers for Disease Control and Prevention. (2008). The youth risk behavior
surveillance-United States, 2007. [Electronic Version]. Surveillance Summaries.
MMWR, 57 (SS-4), 1-136. Retrieved October 20,2008, from:
http://www.cdc.gov/HealthyYouthlyrbs/pdf/yrbss07_mmwr.pdf
Center for Disease Control and Prevention. (2009). Overweight and obesity.
Retrieved June 26, 2007, from:
http://cdc.gov/nccdphp/dnpa!obesity/childhood/contributing_factors.htm
Clark, H., Goyder, E., Bissell, P., Blank, L., & Peters, J. (2007). How do parents' child
feeding behaviors influence child weight? Implications for childhood obesity
policy. Journal of Public Health, 29(2), 132-141. Retrieved November 29,2008,
from: http://jpubhealth.oxfordjoumals.orglcgi/reprint/fdmOI2vl
Colapinto, C., Fitzgerald, A., Taper, J., & Veugelers, P. (2007, July). Children's
preference for large portions: prevalence, determinants, and consequences.
Journal of the American Dietetic Association, 107(7), 1183-1190.
Coon, K., Goldberg, J., Rogers, B., & Tucker, K. (2001). Relationships between
use of television during meals and children's food consumption patterns.
Pediatrics, 107(1), 1-9. Retrieved October 4, 200S, from:
http://pediatrics.aappub lications.orgl cgi/reprintll 07/1/ e7
59
Cruz, M., & Goran, M. (2004). The metabolic syndrome in children and adolescents.
Current Diabetes Reports, 4(1), 53-62. Retrieved December 22, 200S, from:
http://www.springerlink.com/contentI2714505S73006174/
Deckelbaum, R, & Williams, C. (2001). Childhood obesity: The health issue.
Obesity Research, 9(4), 239S-243S. Retrieved June IS, 2007, from:
www.obesityresearch.org/cgi/content/fu1l9/suppl_4/S239
De Ferranti, S. & Osganian, S. (2007). Epidemiology of pediatric metabolic syndrome
and type 2 diabetes mellitus. Diabetes and Vascular Disease Research, 4(4), 2S5-
296. Retrieved March 13,2009, from:
http://www.dvdres.com/pdfI2S95/VoI4_Num4_December_2007 ~2S5-296.pdf
Eisenberg, M., Neumark-Sztainer, D., & Story, M. (2003). Associations of
weight-based teasing and emotional well-being among adolescents. Archives 0/
Pediatric & Adolescent Medicine, 157(S), 733-73S. Retrieved November 2S,
200S, from: http://archpedi.ama-assn.orglcgi/reprintIl57 IS/733
Eisenmann, J., Bartee, R, Smith, D., Welk, G., & Fu., Q. (200S). Combined influence of
physical activity and television viewing on the risk of overweight in US youth.
International Journal a/Obesity, 32(4), 613-61S. Retrieved September 23, 200S,
from http://www.nature.com/ij o/j ournal/v3 2/n4/pdf/OS03 SOOa. pdf
Faith, M., Berkowitz, R, Stallings, V., Kerns, J., Storey, M., & Stunkard, A. (2004).
Parental feeding attitudes and styles and child body mass index: Prospective
analysis of a gene-environment interaction. Pediatrics, 114(4), e429-e436.
Retrieved November 29, 2008, from:
http://pediatrics.aappublications.org/cgi/reprint/114/4/e429
60
Faith, M., Pietrobelli, A., Nunez, C., Heo, M., Heymsfield, S., & Allison, D. (1999).
Evidence for independent genetic influences on fat mass and body mass index in a
pediatric twin sample. Pediatrics, 104(1),61-67. Retrieved May 21,2008, from:
http://pediatrics.aappub lications.org/ cgil contentl abstract/1 04/1/61
Farrow, C. & Blissett, J. (2006). Does maternal control during feeding moderate early
infant weight gain? Pediatrics, 118(2), e293-298. Retrieved December 1, 2008,
from: http://pediatrics. aappublications.org/ c gi/reprintl 118/21 e293
Freedman, D., Mei, Z., Srinivasan, S., Berenson, G., & Dietz, W. (2007). Cardiovascular
risk factors and excess adiposity among overweight children and adolescents: The
bogalusa heart study. Journal of Pediatrics, 150(1), 12-17. Retrieved April 18,
2009, from: http://www.jpeds.comlartic1e/S0022-34 7 6(06)00817 -1 Ipdf
Fulkerson, J., Neumark-Sztainer, D., & Story, M. (2006). Adolescent and parent views
of family meals. Journal of the American Dietetic Association, 106(4),526-532.
Retrieved December 23, 2008, from
http://download.journals.elsevierhealth.comlpdfs/journals/0002-
82231PIIS0002822306000071. pdf
Fulkerson, J., Story, M., Neumark-Sztainer, D., & Rydell, S. (2008, April). Family meals:
Preceptions of benefits and challenges among parents of 8-to 10-year-old
children. Journal of the American Dietetic Association, 108(4),706-709.
Golan, M., & Crow, S. (2004). Targeting parents exclusively in the treatment of
childhood obesity: Long-term results. Obesity Research, 12(2), 357-361.
Retrieved December 23,2008, from:
http://www.nature.comloby/journal/v12/n2/pdf/oby200445a.pdf
61
Gordon-Larsen, P., Adair, L., & Popkin, B. (2002). Ethnic differences in physical
activity and inactivity patterns and overweight status. Obesity Research, 10(3),
141-149. Retrieved October 4,2008, from:
http://www.nature.com/oby/j ournal/v 1 0/n3/pdf/ oby200223a.pdf
Gortmaker, S., Must, A., Perrin, J., Sobol, A., & Dietz, W. (1993). Social and
economic consequences of overweight in adolescence and young adulthood. New
England Journal of Medicine, 329(14), 1008-1012. Retrieved November 26,
2008, from: http://content.nejm.org/cgi/content/fu1ll329114/1 008
Hassink, S. (2006). A parent's guide to childhood obesity: A road map to health.
USA: American Academy of Pediatrics
Hossain, P., Kawar, B., El Nahas, M. (2007). Obesity and diabetes in the
developing world-a growing challenge. New England Journal of Medicine,
356(3),213-215. Retrieved December 11, 2007, from:
http://content.nejm.org/cgi/content/fu1ll356/31213
Huang, T. (2007). Finding thresholds of risk for components of the pediatric
metabolic syndrome. Journal of Pediatrics, 152(2), 158-159. Retrieved June
4,2008, from: http://download.journals.elsevierhealth.comlpdfs/journals/0022-
3476IPIIS002234760700892X.pdf
Ikeda, P. (2007, January). Promoting family meals and placing limits on television
viewing: Practical advice for parents. Journal of the American Dietetic
Association, 107(1),62-63.
62
International Association for the Study of Obesity. (n.d.) Childhood Obesity. Retrieved
December 28,2008, from: http://iotf.org/chi1dhoodobesity.asp
Institute of Medicine. (2004). Advertising, marketing and the media: Improving
messages. Retrieved December 29,2008, from:
http://www.iom.edu/Object.Fi1elMasterI22/609/fact%20sheet%20-
%20marketing%20finaBi tticks. pdf
International Obesity Taskforce. (n.d.) Childhood Obesity. Retrieved Apri114, 2009,
from: http://www.iotf.org/chi1dhoodobesity.asp
2008, from: http://content.nejm.org/cgi/content/fu11l32911411008
Janssen, 1., Craig, W., Boyce, W., & Pickett, W. (2004). Associations between
overweight and obesity with bullying behaviors in school-aged children.
Pediatrics, 113(5), 1187-1194. Retrieved November 16,2008,
from: http://www.pediatrics.org/cgi/content/fu11l113/511187
Kahn, J. (1982). Child development-problems of discipline, authority, and rebellion.
Western Journal of Medicine, 86(5),314-320. Retrieved Apri16, 2009, from:
http://www . pubmedcentral.nih. gov Ipicrender. fcgi? artid= 1511901 &b1obtype=pdf
Kaiser Family Foundation. (2004). Kaiser family foundation releases new report on role
ofmedia in childhood obesity. Retrieved December 29,2009, from:
http://www.kff.org/entmediaientmedia022404nr.cfin
Kaiser Family Foundation. (2007). Food for thought-television food advertising to
63
children in the United States. [Electronic Version]. Retrieved December 29,2009,
from: http://www.kff.org/entmedia/upload/761S.pdf
Kaur, H., Choi, W., Mayo, M., & Harris, K. (2003). Duration of television
watching is associated with increased body mass index. Journal of Pediatrics,
143(4),506-511. Retrieved October 4, 200S, from:
http://www.jpeds.com/article/S0022-3476(03)0041S-9/pdf
King, B (2007, September). Childhood Obesity. Alive, 299, 36-3S.
Kirk, S., Scott, B., & Daniels, S. (2005, May). Pediatric obesity epidemic: treatment
options. Journal of the American Dietetic Association, 1 05( 5), S44-S5l.
Kubik, M., Story, M., Davey, C., Dudovitz, B., Zuehlke, E. (200S, November). Providing
obesity prevention counseling to children during a primary care clinic visit:
Results from a pilot study. Journal of the American Dietetic Association, 1 08( 11),
1902-1906.
Krah, T., Roe, L., & Rolls, B. (2004). Combined effects of energy density and
portion size on energy intake in women. American Journal of Clinical Nutrition,
79(6), 962-96S. Retrieved September 2, 200S, from:
http://www.ajcn.orglcgi/reprint/79/6/962
Larson, N., Neumark-Sztainer, D., Hannan, P., & Story, M. (2007, September). Family
meals during adolescence are associated with higher diet quality and healthful
meal patterns during young adulthood. Journal of the American Dietetic
Association, 107(9), 1502-1510.
LaRowe, T., Moeller, S., & Adams, A. (2007, July). Beverage patterns, diet
quality, and body mass index of US preschool and school-aged children.
64
Journal of the American Dietetic Association, 107(7), 1124-1133.
Ludwig, D., Peterson, K., & Gortmaker, S. (2001). Relation between consumption of
sugar-sweetened drinks and childhood obesity: a prospective, observational
analysis. The Lancet, 357(9255), 505-508. Retrieved December 22,2008 from:
http://www.thelancet.com/journals/lancet/article/PIISOI40-6736(00)04041-
lIfulltext
Ludwig, D. (2007). Ending thefoodfight. New York, NY: Houghton Mifflin Co.
Matheson, D., Killen, J., Wang, Y., Varady, A., & Robinson, T. (2004). Children's
food consumption during television viewing. American Journal of Clinical
Nutrition, 79(6), 1088-1094. Retrieved October 4, 2008, from:
http://www.ajcn.org/cgi/reprintI79/6/1088
Mayo Foundation for Medical Education and Research. (2007). Metabolic Syndrome.
Retrieved July 7, 2008, from
http://www.mayoclinic.com/health/metabolic%20syndromeIDS005 22
McConahy, K., Smiciklas-Wright, H., Birch, L., Mitchell, D., & Picciano, M.
(2002). Food portions are positively related to energy intake and body weight in
early childhood. Journal of Pediatrics, 140(3),340-347. Retrieved July 14, 2008,
from: http://www.jpeds.com/article/S0022-3476(02)19487-Xlpdf
McGill, H., McMahan, A., Herderick, E., Zieske, A., Malcom, G., Tracy, R., M., Strong,
J. (2002). Obesity accelerated the progression of coronary atherosclerosis in
young men. Journal of the American Heart Association, 105(23),2712-2718.
Retrieved November 15, 2008, from:
http://circ.ahajournals.org/cgi/reprint/l0512312712
65
Monty, c., Handu, D., & Chmel, L. (2008). Nutrition education intervention among
children decreased body mass index and increased test scores in nutrition
knowledge, behavior, and intention. Journal of the American Dietetic Association,
108(9), A97. Retrieved March 28, 2009, from:
http://download.joumals.elsevierhealth.comlpdfs/j oumals/0002-
8223IPIIS00028223080 1 0882.pdf
Nader, P., O'Brien, M., Houts, R, Bradley, R, Belsky, J., Crosnoe, R, et al. (2006).
Identifying risk for obesity in early childhood. Pediatrics, 118(3), e594-e60 1.
Retrieved December 28, 2008, from:
http://www.pediatrics.org/cgi/content/fullIl18/3/e594
National Heart Lung and Blood Institute. (n. d.). About hearts n' parks. Retrieved
January 3, 2009, from:
http://www.nhlbi.nih.gov/health/prof/heart/obesitylhrt_n~klhnp_ab.htm
National Institute of Child Health and Human Development. (2006). Overweight
in early childhood increases chances for obesity at age 12. Retrieved June 26,
2007, from:
http://www.nichd.nih.gov/news/releases/obesity _risk_early _ childhood.cfm
National Institute of Diabetes and Digestive and Kidney Diseases. (2006). Insulin
resistance and pre-diabetes. Retrieved December 29,2008, from:
http://diabetes.niddk.nih.govIDM/pubs/insulinresistance/
National Institute of Diabetes and Digestive and Kidney Diseases. (2007).
Statistics related to overweight and obesity. Retrieved June 26,2007,
from: win.niddk.nih.gov/statistics/index.htm#other
66
National Recreation and Park Association. (2004). Hearts N' Parks - report of 2004
magnet center performance data. United States Department of Health and Human
Services. Retrieved December 27, 2008, from:
http://www .nhlbi.nih. gov/health/proflheartl obesity/hrt _n ~k/2004 _report. pdf
National Restaurant Association. (2009). Industry research. Retrieved December 28,
2008, from: http://restaurant.org/research/
Nelson, M., Neumark-Stzainer, D., Hanan, P., Sirard, J., & Story, M. (2006).
Longitudinal and secular trends in physical activity and sedentary behavior during
adolescence. Pediatrics, 118(6), eI627-eI634. Retrieved March 22,2009, from:
http://pediatrics.aappublications.org/cgi/reprintI118/6/eI627
Nelson, M., Lytle, L., & Pasch, K. (2009, February). Improving literacy about energy
related issues: The need for a better understanding of the concepts behind energy
intake and expenditure. Journal of the American Dietetic Association, 109(2),
281-287.
Nemet, D., Barkan, S., Epstein, Y., Friedland, 0., Kowen, G., & Eliakim, A. (2005).
Short-and long-term beneficial effects of a combined dietary-behavioral-physical
activity intervention for the treatment of childhood obesity. Pediatrics, 115(4),
e443-e449. Retrieved October 4, 2008, from:
http://pediatrics.aappublications.org/cgi/reprintI115/ 4/e443
Nestle, M. (2006). Food marketing and childhood obesity-a matter of policy.
New England Journal of Medicine, 354(24),2527-2529. Retrieved
December 11,2007, from: http://content.nejm.org/cgi/content/full/354/24/2527
Obesity Society (2007). Childhood overweight. Retrieved June 26,2007, from:
67
www.naaso.org/information/childhood_overweight.asp
O'Dea, J. (2003, April). Why do kids eat healthful food? Perceived benefits of and
barriers to healthful eating and physical activity among children and adolescents.
Journal of the American Dietetic Association, 103(4), 497-50l.
Okie, S. (2005). Fed up. Washington, DC: Joseph Henry Press.
Pan, Y., & Pratt, C. (2008). Metabolic syndrome and its association with diet and
physical activity in us adolescents. Journal of the American Dietetic Association,
108(2),276-286. Retrieved June 6, 2008, from:
http://download.joumals.elsevierhealth.comlpdfs/j oumals/0002-
8223IPIIS0002822307020780.pdf
Proctor, M., Moore, L., Gao, D., Cupples, L., Bradlee, M., Hood, M., et al. (2003).
Television viewing and change in body fat from preschool to early adolescence:
the Framingham children's study. International Journal of Obesity 27(7),827-
833. Retrieved October 4,2008, from:
http://www.nature.comlij o/j oumallv2 7 In 7 Ipdfl0802294a. pdf
Ritchie, L., Welk, G., Styne, D., Gerstein, D., & Crawford, P. (2005). Family
environment and pediatric overweight: what is a parent to do. Journal of the
American Dietetic Association, 105(5), S70-S79. Retrieved June 18,2007, from
http://download.joumals.elsevierhealth.comlpdfs/j oumals/0002-
8223IPIIS000282230500 1562.pdf
Rolls, B., Roe, L., Meengs, J., & Wall, D. (2004). Increasing the portion size ofa
sandwich increases energy intake. Journal of the American Dietetic Association,
104(3),367-372. Retrieved September 2,2008, from:
http://download.joumals.elsevierhealth.com/pdfs/joumals/0002-
82231PIIS00028223030 1784X.pdf
Rolls, B., Roe, L., & Meengs, J. (2006). Reductions in portion size and energy
68
density of foods are additive and lead to sustained decreases in energy intake.
American Journal of Clinical Nutrition, 83, 11-17. Retrieved September 2,2008,
from: http://www.ajcn.org/cgi/reprint/831l1l1
Satter, E. (2005). Your child's weight: Helping without harming. Madison, WI: Kelcy
Press
Schwartz, M., & Brownell, K. (2007). Actions necessary to prevent childhood obesity:
Creating climate for change. Journal of Law, Medicine, & Ethics, 35(1), 78-89.
Retrieved December 12,2008, from:
http://www3.interscience.wiley.com/joumalIl18497556/abstract
Schwartz, M., & Chadha, A. (2008). Type 2 diabetes mellitus in childhood: Obesity and
insulin resistance. Journal of the American Osteopathic Association, 108(9), 518-
524. Retrieved December 28, 2008, from:
http://www.jaoa.org/cgi/reprintIl08/9/518
Sjoberg, R., Nilsson, K., & Leppert, J. (2005). Obesity, shame, and depression in school
aged children: A population-based study. Pediatrics, 116(3), e389-e392.
Retrieved January 15, 2009, from:
http://pediatrics.aappublications.org/cgi/reprint/116/3/e3 89
Snoek, H., Engels, R., Janssens, J., & van Strien, T. (2007). Parental behavior and
adolescents' emotional eating. Appetite, 49(1),223-230. Retrieved December 22,
2008, from: http://www.sciencedirect.com/science
Speakman, J. (2004). Obesity: The integrated roles of environment and genetics.
Journal o/Nutrition, 2090S-2102S. Retrieved June 8, 2008, from:
http://jn.nutrition.org/cgi/reprint/134/8/2090S
69
Stice, E., Agras, W.S., & Hammer, L.D. (1999). Risk factors for the emergence of
childhood eating disturbances: A five-year prospective study. International
Journal 0/ Eating Disorders, 25(4),375-387. Retrieved December 22,2008,
from: http://cat.inist.frl?aModele=afficheN &cpsidt= 1746430
St. Jeor, S., Perumean-Chaney, S., Sigman-Grant, M., Williams, C., & Foreyt, J. (2002). Family
based interventions for the treatment of childhood obesity. Journal of the American
Dietetic Association, 102(5), 640-644. Retrieved December 3,2007, from:
http://download.joumals.elsevierhealth.com/pdfs/joumals10002-
8223IPIIS000282230290 146X.pdf
Strauss, R. (2000). Childhood obesity and self-esteem. Pediatrics, 105(1), 1-7. Retrieved
November 16, 2008, from:
http://pediatrics.aappublications.org/cgi/reprint/l05/1/eI5
Temple, J., Giacomelli, A., Kent, K., Roemmich, J., & Epstein, L., (2007).
Television watching increases motivated responding for food and energy
intake in children. American Journal of Clinical Nutrition, 85(2), 355-361.
Retrieved June 18,2007, from: http://www.ajcn.org/cgi/reprint/85/2/355
Troiano, R., Briefel, R., Carroll, M., Bialososky, K. (2000). Energy and fat
intakes of children and adolescents in the United States: data from the national
health and nutrition examinination surverys. American Journal of Clinical
Nutrition, 72(5), S1343-S1353. Retrieved July 14, 2008, from:
http://www.ajcn.org/cgi/reprintI72/511343
70
United States Census Bureau. (2005-2007). Fact sheet: Dunn County, Wisconsin.
Retrieved December 29,2008, from:
http://factfinder.census.gov/servlet/ ACSSAFFFacts? _ event=Search&geo _id=&_g
eoContext=& _ street=& _ county=dunn+county& _ cityTown=dunn+county& _state
=04000US55& _ zip=& _lang=en& _ sse=on&pctxt=fph&pgsl=O 1 0
Wake, M., Nicholson, J., Hardy, P., & Smith, K. (2007). Preschooler obesity and
parenting styles of mothers and fathers. Australian national population study.
Pediatrics, 120(6), eI520-eI527. Retrieved April 18, 2009, from:
http://www.pediatrics.org/cgi/content/fullI120/6/e 1520
Wardle, J., Carnell, S., & Cooke, L. (2005, February). Parental control over feeding and
children's fruit and begetable intake: How are they related? Journal of the
American Dietetic Association, 105(2),227-232.
Wardle, J., Carnell, S., Haworth, C., & Plomin, R (2008). Evidence for a strong genetic
influence on childhood adiposity despite the force ofte obesogenic environment.
American Journal of Clinical Nutrition, 87(2),398-404. Retrieved November 23,
2008, from:http://www.ajcn.org/cgi/reprint/87/2/398
Weiss, R, Dziura, J., Burgert, T., Tamborlane, W., Taksali, S., Yeckel, C., et al.
(2004). Obesity and the metabolic syndrome in children and adolescents. New
England Journal of Medicine, 350 (23),2362-2374. Retrieved March 2,2008,
from: http://content.nejm.org/cgi/reprint/350/2312362.pdf
Weiss, R, & Kaufman, F. (2008). Metabolic complications of childhood obesity:
71
Identifying and mitigating the risk. Diabetes Care, 31 (2), S310-S316. Retrieved
January 15,2009, from:
http://care.diabetesjournals.org/cgi/reprint/31 ISupplement_ 2/S310
Wilson, P., D' Agostino, R., Parise, H., Sullivan, L., & Meigs, J. (2005). Metabolic
syndrome as a precursor of cardiovascular disease and type 2 diabetes mellitus.
Journal o/the American Heart Association, 112(20),3066-3072. Retrieved
November 24, 2008, from
http://www.circ.ahajournals.org/cgi/reprint/CIRCULATIONAHA.105.539528vl
Wrotniak, B., Epstein, L., Paluch, R., & Roemmich, J. (2004). Parent weight change as a
predictor of child weight change in family-based behavioral obesity treatment.
Archives o/Pediatrics & Adolescent Medicine, 158(4),342-347. Retrieved
December 3,2007, from: http://archpedi.ama-assn.org/cgi/reprintlI58/4/342
World Health Organization. (2006). Obesity and overweight. Retrieved December 28,
2008, from: http://www.who.int/mediacentre/factsheets/fs3111eniindex.html
Young, L., & Nestle, M. (2003) Expanding portion sizes in the US marketplace:
implications for nutrition counseling. Journal 0/ the American Dietetic
Association, 103(2), 231-234. Retrieved July 14, 2008, from:
http://download.journals.elsevierhealth.comlpdfs/journals/0002-
82231PIIS0002822302000317.pdf
Zoumas-Morse, C., Rock, C., Soba, E., & Neuhouser, M. (2001). Children's patterns of
macronutrient intake and associations with restaurant and home eating. Journal
o/the American Dietetic Association, 101(8),923-925. Retrieved September 2,
72
2008, from: http://downIoad.joumaIs.eIsevierhealth.com/pdfs/j oumaIs/0002-
82231PIIS0002822301002280.pdf
73
Appendix A: IRB Approval Fonn
152 Vae Rehab Building
STOUT University of Wisconsin-Stout P.O. Box 790
Date:
To:
From:
Subject:
Menomonie. WI547510790
715/232-1126 715/232-1749 (fax) http /Iwww uwstOliL()sitj/r"r
February 7, 2007
Ann Parsons Leah Karaliunas Diane Rasmussen Wendy Knutson Carolyn Barnhart
Sue Foxwell, Research Administrator and Human Protections Administrator, UW -Stout Institutional Review Board for the Protection of Human Subjects in Research (lRB)
Protection of Human Subjects
74
Your project, "Family-based Intervention to Reduce Childhood Obesity in Dunn County," has been approved by the IRB through the expedited review process. The measures you have taken to protect human subjects are adequate to protect everyone involved, including subjects and researchers.
Reviewer comment: This research is extremely worthwhile for the community!
Please copy and paste the following message to the top of your survey form before dissemination:
This research has been approved by the UW-Stout IRB as required by the Code of I Federal Regulations Title 45 Part 46.
This project is approved through February 6, 2008 modifications to this approved protocol need to be approved by the IRB. Research not completed by this date must be submitted again outlining changes, expansions, etc. Federal guidelines require annual review and approval by the IRB.
Thank you for your cooperation with the IRB and best wishes with your project *NOTE: This is the only notice you will receive - no paper copy will be sent.
75
Appendix B: Infonnational Flier for Recruitment
76
~ImOw@[f§if1y @if @!m5nlfU~ ~t@Mi
rDMlfuu ~@MlfilftJ ~~Il ~~mlrttm~m
~ O~I~ C@m@~
Facility:
6 W'eek Program f01' the Entire Family 10 Sessions APRll. 2r.1 tlu'Ough May 9'· Thne: 6 p.m. to 8 p.m.
Monday < Aprll 211, 9'·, 16'h, 23rd,30'. 1k'l}' 7'.
W'ednesday • AprU 18'·, 25,h .t.{..'1}'2~,9'·
ENTIRE FAMILY ENCOURAGED TO ATIEND
Thank yon for your interest! If you "!'I.mt to participate please send lIS your application:
Jan Pejsa Rt-K Edu:ation Red Cedar Medical Center 2321 Stout Rd Menomonie., Wisccmin 54751 1-715-233-7SS9 pejsa .janG'mayo.ed u
PERKS & GIFTS INCLUDED: SNACKS t PEDOMETERS, & MORE!
77
Appendix C: Informational Packet for Families
78
Consent to Participate in UW-Stout Approved Research Program
Title: Family-Based Program to Increase Nutritious Eating and Physical Activity
Investigators: A coalition composed of Red Cedar Medical Staff - part of Mayo Health Systems (RCMC), UW-Stout, and Dunn County Public Health Department (PHD)
Description: The family-based program has been created to benefit families in the Dunn county area. This program offers families fun activities promoting:
• Nutrition education • Strategies for healthier eating • Ways to increase physical activity in the home environment
Risks and Benefits: Benefits for all participants are:
• Opportunities to learn the advantages of healthy eating • Ability to participate in supervised physical activity • Having nutritious foods available • Receiving skills and tools to use at home
There are minimum risks associated with this program. Participating families will be asked to fill out questionnaires and surveys related to:
• Nutrition • Ability to incorporate healthy • Dietary habits lifestyles into the family structure • Lifestyle habits focusing on • Understanding of the eating
physical activity relationship
• Attitude
Weight, height and body composition measurements will be taken for each family member. All measurements will be obtained while standing on a scale, in a private setting!. Participants will only be asked to remove shoes and outer jacket (if wearing one). All data will be kept confidential in a secured area.
Special Populations: The program will include the participation of minors. Families who have children between the ages of eight to ten are asked to participate. The entire family will also be asked to participate no matter the age or number of other children.
Time Commitment and Payment: Participation in this program will require and include the following:
• Ten support group sessions: one to two hours in length up to two sessions a week, over a six week period
• Two home visits with our staff joining the family during meal time.
79
NOTE: The families will be compensated with free handouts, new meal ideas, and new activities for the whole family to participate. Families that successfully complete every component ofthe program will receive a thank you gift, value of approximately $50.00
.
Confidentiality: Your name will not be included on any data sheets. This informed consent sheet containing your name will not be kept with any of the other documents. You and your family will be given a unique identification code number by which all data collected will be identified by. The principle investigator and specified staff members will be the only ones with access to the decoding sheets that are to be kept in a locked space. Decoding and data sheets, stored in separate locations, will be retained for future studies.
Right to Withdraw: Your participation in this study is entirely voluntary. You may choose not to participate in the study. Or should you choose to participate and later wish to withdraw, you may discontinue at that time. There will be no adverse consequences involved. You will be allowed to keep any materials given to you up to the point of discontinuing your participation.
IRB Approval: This study has been reviewed and approved by The University ofWisconsin-Stout's Institutional Review Board (IRB). The IRB has determined that this study meets the ethical obligations required by federal law and university policies.
If you have questions or concerns regarding this study please contact the Investigator. If you have any questions, concerns, or reports regarding your rights as a research subject, please contact the IRB Administrator
Investigator Dr. Ann Parsons 203J Science Wing University of WI-Stout Menomonie, WI 54751 (715)232-2563 [email protected]
IRB Administrator: Sue Foxwell, Director, Research Service 152 Vocational Rehabilitation Bldg. University of WI-Stout Menomonie, WI 54751 (715)232-2477 [email protected]
80
Appendix D: Infonned Consent
81
Statement of Consent: By signing this consent form you and your dependent minor(s) agree to participate in the project entitled, Family-Based Program to Increase Nutritious Eating and Physical Activity.
Name of 1 st adult family member
1 st Adult family member Signature Date
Name of 2nd adult family member
2nd Adult family member Signature Date
Participating Minors:
Name Age Consent of Legal Guardian
82
Appendix E: Letter to Councilors and Teachers
83
February 12,2007
Dear Councilors and Teachers,
Red Cedar Medical Center, the University of Wisconsin-Stout, Dunn County Public Health, and the Menomonie School District recently received a rural health grant entitled "Family-based interventions to reduce childhood obesity in Dunn County." The grant is approximately $50,000. A grant of this size could do a lot for our community and we are excited to get started on this project. There will be no fees for the 20 families associated with this program. The focus ofthe program is on children ages eight to ten; however every family member will take part in the program. Opportunities the program will offer:
• In home one on one nutrition and meal preparation education • A family interaction evaluation • Evening group sessions; where families will gather further information, including
a meal, guest speakers, and exercise time with trainers • Community presentations • Fun, Food, and Fitness activities in the schools
Although the program is in its preliminary stages, we feel communication with you is important. Within the next month we will be sending informational letters to families. We ask that you assist in identifying families with children ages eight to ten years old in your schools that could benefit greatly from this program.
I am working with Jan Pejsa, Red Cedar Medical Center; she will be the person collecting the names of families. If you have additional questions please contact me via email at [email protected].
Sincerely,
Leah Karaliunas Program Coordinator [email protected]
Jan Pejsa Community Education Coordinator 715-233-2889 [email protected]
84
Appendix F: Child Questionnaire
Which food is better for your health? gl
Cc<lC«u!
~·.t ~ ~.:..;Jarlnk
~~ ~
G ___ -3..i.od
~ GOatES
:J ~ Bcri}'\!;iJ"50,j
:J~, "!)()!l1VO:HSe"
~ ~;v-:B.1IXl1
I ''--~a-FaI-"H"':'t
, CW,8w
85
86
What foods do you eat
most of the time? .t»mr.t»nl: Ct"e~~dltl!MCIt>::od50.iI)'CUQf""(l5IOI*n.
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87
88
Appendix F: Adult Questionnaire
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I
I 'Possible causes of
high blood pressure
91