Family-oriented nutrition education and preschool obesity

Family-Oriented Nutrition Education and Preschool Obesity Maurine Venters and Rebecca Mullis Division ofEpidemiology, School of Public Health, University ofMinnesota, Minneapolis, Minnesota 55455 Growing concern about early childhood obesity and its potential association with future health problems has stimulated nutritionists and other health professionals to conduct an increasing number of investigations (1-4). Although researchers disagree as to the importance of genetic, metabolic, and/or environmental factors in the etiology of obesity, selected studies provide evidence that environmental modification programs are an effective means of obesity control (4-7). Due to the central role offamily life in children's daily activities, it appears that family-oriented intervention is essential both for weight modification and long-term maintenance of weight loss in young children. Such intervention is supported in the literature of family theory, which has long recognized the family as the unit of decision making, planning, and action with regard to health and illness (8). In this review we explore implications of interdisciplinary findings in an attempt 1) to identify family practices and behaviors that contribute to preschool obesity and 2) to suggest effective obesity control strategies that can guide family-oriented nutrition education and counseling efforts. FAMILY ENVIRONMENTAL FACTORS AND PRESCHOOL OBESITY CONTROL Nutritionists have attributed obesity to an imbalance between the food energy consumed and the physical energy expended. Thus, sedentary lifestyles and an overconsumption of calories are the two most appropriate aspects of family environment on which to focus obesity control efforts. Health professionals have established prevention as a high priority, due to limited success in reversing early childhood obesity (5). Thus far, however, preventive strategies have been limited to encouraging modification of eating patterns during the prenatal or infancy period. Parental nutrition education and support of breast feeding have helped prevent overfeeding. One unique program directed toward minimizing the incidence of obesity among infant participants focused upon periodically determining each participant's dietary needs based

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upon that individual's growth pattern. Study findings concluded that this personalized approach was more successful in preventing infant obesity than an approach that emphasized general nutritional information to the group as a whole (9). For young children who are overweight, altering family lifestyle has yielded varying degrees of success (10, 11). Studies exploring the causes of addictive behavior have supported intervention efforts that focus on underlying family factors contributing to obesity rather than on the obese individual. This research has concluded that in cases of obesity there is at least one family member and often several family members who act as "enablers" in promoting and maintaining the excessive weight (12). These findings, unfortunately, fail to identify specific underlying family factors that influence obesity. Although few investigators have explored family characteristics that account for variation in obesity, selected studies (4, 13-16) have focused on family values, beliefs, and modes of interaction, as partial determinants of family lifestyle. Awareness of these dimensions of family life promotes a more accurate assessment of factors that influence preschool obesity, and may facilitate the implementation of an effective solution. Thus, by learning and using family assessment techniques and skills, nutritionists can maximize their effectiveness: They are able to communicate nutrition information to a wide variety of families that have differing modes of interaction and belief systems. Family values and beliefs. Social learning theory assumes that observing the behavior of others is the major mode oflearning (14). This is especially true for young children who use their parents and other family members as role models, thereby acquiring and integrating values, beliefs, and behavior patterns that frequently persist into adulthood (17). Garn and Clark (18) demonstrated this socialization process when they observed daily family dietary and physical activity practices of obese parents. Their observations revealed that parents who were accustomed to eating large quantities of food tended to overfeed their chil-

dren. In addition, these parents lacked interest in physical activities. This finding helped lead to the conclusion that poor dietary practices coupled with inadequate levels of physical activity are major factors in the development of obesity. Similarly, Harris et al. (19) demonstrated that physically active parents are more interested in the sports activity and fitness of their children than are nonactive parents. Nutritionists can help families adopt healthier lifestyles by facilitating changes in the expectations about the role of food in child nurturing, by promoting realistic goals, and by focusing upon small changes over long periods oftime. For example, parents who interpret their infant's cry for attention as a cry for food may need to explore a variety of interpretations of their infant's behavior in order to avoid establishing a pattern of overfeeding. An infant's cry may indicate a need for physical closeness or a desire to alleviate physical discomfort rather than a need for more food. Parents of an obese preschooler may need to learn about nutrition and exercise, and they may need to learn how they can alter their physical and social home environment to avoid a family lifestyle that inhibits positive habit changes in their child. The nutritionist can promote this kind of learning by emphasizing incremental changes leading to short-term accomplishments, followed by positive feedback and renewed goal setting. Some families, for example, may monitor and graph their child's dietary intake and exercise. Other families may record their food storage, buying, and preparation patterns. A family that performs either activity will provide information about the family's belief system and daily practices. The nutritionist can use this information to suggest specific changes that will lead the family toward a healthier lifestyle. Small positive changes can be reinforced with praise and the establishment of new goals - goals directed toward creating a home environment that discourages overeating and sedentary behavior. Information about the family's belief system lends insights into the health-compromising effects of certain cultural meanings JOURNAL OF NUTRITION EDUCATION

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and provides direction to personalize change strategies. For example, Stunkard (4) observed that in some subcultures obesity in small children is valued as a positive trait because the dominant figure in the home is an obese grandmother. For infants from these environments, obesity results from constant feeding, the intention of which is to promote maximum growth. In this situation, intervention strategies must focus first on changing the family's concept of "healthy," to emphasize thinness rather than fatness, before the family will assume responsibility for modifying overfeeding practices. Beliefs also have influenced parental disciplinary techniques, resulting in the offering or withholding of sweets for rewards or punishment (20). Another potent determinant of children's dietary patterns has been demonstrated by Burt and Hertzler (21), who identified the father's food preferences as a major influence upon the mother's selection and preparation of daily meals. These findings demonstrate the importance of encouraging the whole family to increase their awareness of appropriate menu planning, food selection, and food preparation. Family interaction patterns. Although ac-

curate assessment of family values and beliefs can help personalize obesity control efforts, a family's lifestyle will not be altered simply by increasing their awareness and providing skill-level learning (e.g., teaching the family that an infant's cry may indicate a variety of needs other than hunger). However, an understanding of family interaction patterns can provide the nutrition communicator with insights about the function of existing eating and exercise patterns, and such insights can facilitate selection of the most effective intervention strategies. Sociological studies of the family indicate that daily family life is typified by many dimensions of ongoing interaction, as one member's behavior is continually stimulated by the behavior of other family members (22). Some of these dimensions, such as positive communication (shared meaning resulting in support) and cohesion (commitment of individuals to the family), are functional because they promote survival of the family and personal growth. Others are dysfunctional in the sense that they add stress to the home environment and threaten the emotional support system of the family. A high degree of conflict (anger and aggression) and control (rigid enforcement of rules) as well as lack of adaptability (as indicated by a rigid mode of organization) are three di160

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mensions that characterize (23) dysfunctional family environments associated with inadequate dietary patterns (measured by a Nutritional Adequacy Reporting Score.) Conversely, other investigators found that highly cohesive families have better diets (23). Others (24) have observed that obese children who live in families typified by inadequate communication skills have trouble losing weight. Researchers also have concluded that families experiencing excessive conflict often use food as the focus of discipline and problem solving. In these families, adults may react to daily stress by overeating, or they may encourage their children to minimize their frustration by indulging in sweets (20). Because a change in diet would remove a source of satisfaction and add stress to the already existing family tension, the nutritionist must first consider the source of stress and then deal with inappropriate eating behavior. For example, investigators have found that parents who disagree about child-rearing techniques frequently rear overweight children who have poor nutrient intakes (20). Conversely, children of parents who agree on child-rearing techniques tend to have eating patterns that provide them with nutrients equal to 90 percent of recommended dietary allowances (20). Therefore, before focusing on the obesity problem, effective nutritional counseling will assist families to identify and, if necessary, to seek help in minimizing this source of conflict. Stress that results from events that cannot be eliminated can be modified if families are able to adopt positive coping strategies instead of overeating. For example, in the case of families that are managing chronic severe illness, the nutritionist may guide the family in securing outside support to cope with the burdens of the illness and then emphasize change toward healthier eating practices. Family sociologists (25) have observed that successful coping involves the ability to communicate and solve problems while under stress. Certain communication patterns appear to be more conducive to problem solving and decision making than others. Investigators of family interaction (26) have concluded that families that work well together possess a flexible verbal and nonverbal communication style, are sensitive to each others' expectations, and make decisions as a result of a melding of opinions by all members. Conversely, families in which decision making is controlled by one or both parents are usually too rigidly organized and controlled to accommodate change. For these families, intervention efforts may

focus on creating a more egalitarian home environment by encouraging open discussion of new diet information and opportunities for increased physical activity. For example, children can enhance their selfperception as contributing family members by participating in menu planning or grocery shopping. Or the father may be encouraged to increase his commitment to a healthier lifestyle by determining which family recreational opportunities in the community fit the family budget and presenting these options to the family. Active participation by all members not only promotes individual responsibility, a positive self-image, and growth through behavior change; it also promotes a commitment to achieve and to maintain the new lifestyle. It is important for the nutritionist to recognize variation in the degree of openness of family boundaries because such variation may influence awareness and acceptance of new health information and programs. Socially active families that maintain ongoing positive communication with friends, neighbors, and community groups may be continually exposed to a wide range of health information from which to choose the best ideas and programs to meet family needs. In contrast, socially isolated families may be more dependent upon the nutritionist to direct their attention to appropriate community resources. If, for example, a family uses overeating as a means to cope with stress, the nutritionist may need to encourage this family to initate and maintain involvement in community programs that encourage use of low-calorie foods and exercise as stress releasers. This degree of ongoing support may not be necessary for socially active families who have already established an identity with the community in which they live. In addition, professionals attempting to guide family lifestyle change toward weight reduction will benefit from insights into the ways in which families differ in their approaches to problem solving. Family problem-solving styles have been described as varying in three aspects (16). The first of these is the degree to which families can detect patterns underlying the complexity of the problems they face. By increasing family awareness of the dangers of promoting the "clean plate club" or of offering sweets as rewards, the nutritionist can help the family discover patterns of behavior that promote obesity in their child. Second, families vary in degrees of coordination, cooperation, and agreement as they progress through the phases of problem solving. Reiss and Oliveri VOLUME

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(16) have drawn upon family research and have outlined this process to include a) a definition of the event and a search for additional information, b) the initial response and trial solutions, and c) a final decision and commitment. The nutritionist can be supportive as a guide and, if necessary, as an arbitrator who moves the family through each of these stages toward the goal of weight reduction, using family food patterns as the focus of discussion. Initial nutrition counseling may focus upon the meaning and function of the eating behavior and identification of the health-compromising effects of this pattern. Counseling can then be directed toward substitution of healthier dietary practices, evaluation of these trials, and commitment toward more appropriate family eating patterns. Finally, families vary greatly regarding openness to new information. Some families reach early decisions based on their convictions and ideas from the past. Assisting these families to choose the best solution may involve delaying their commitment to a long-term obesity control plan until they have obtained and integrated all the necessary new information. These families, for example, would benefit from specific" how to" suggestions concerning changes in their lifestyles in the direction of healthier practices, frequent re-evaluations, and support for small accomplishments. The long-term

plan to control obesity can be established after some of the new health information has been successfully applied and accepted. Thus, awareness of families' values, beliefs, and modes of interaction that influence eating and physical activity patterns enhances the nutritionist's ability to support families in their attempts to control preschool obesity. Awareness of these aspects of family life also permits nutrition educators to identify pathological family behavior, which may be managed best by referral to other community agencies. 0 LITERATURE CITED

I Charney, E., H. Goodman, M. McBride, B. Lyon, and R. Pratt. Childhood antecedents of adult obesity. The New England Journal oj Medicine 295(6):1-4, 1976. 2 Sveger, R. Does overnutrition or obesity during the first years affect weight at age four? Acta Paediatrica Scandinavica 67:465-67, 1978. 3 Mallick, M. Health hazards of obesity and weight control in children: A review of the literature. American Journal of Public Health 73(1 ):78-82, 1983.

4 Stunkard, A. Presidential address: From explanation to ac5 6

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tion in psychosomatic medicine: The case of obesity. Psychosomatic Medicine 37:195~235, 1975. Coates, T.• and C. Thoresen. Treating obesity in children and adolescents: A review. American Journal of Public Health 68:143-51, 1978. U.S. Department of Health, Education, and Welfare. Center for Disease Control. Nutrition surveillance in the United States. Nutrition surveillance. DHEW Pub!. no. 75-8295. Washington, DC: Government Printing Office, 1975, pp. 7-15. Garn, S., S. Bailey, and P. Cole. Effect of parental fatness levels on the fatness of biological and adoptive children. Ecology oJFood and Nutrition 6:1-3, 1976. Litman, T., and M. Venters. Research on health care and the family: A methodological overview. Social Science and Medicine 13A:379-85, 1979. Costom, B., and D. Shore. Effects of a comprehensive nutritional program on the growth and ponderosity of infants. Clinical Pediatrics 22:105-11, 1983.

IO Aragona, J., J. Cassady, and R. Drabman. Teaching overweight children through parental training and contingency contracting. Journal of Applied Behavior Analysis 8:269-78,1975. 11 Wheeler, M., and K. Hess. Treatment of juvenile obesity by successive approximation control of eating. Journal of Behavior Therapy and Experimental Psychiatry 7:235-41, 1976. 12 Shapiro, J. Development of family self-control skills. The Journal oj Family Practice 12(1):67-73, 1981. 13 Hertzler, A. Obesity-impact of the family. Journal oj the American Dietetic Association 79:525-30, 1981. 14 Bandura, A. Social learning theory, Englewood, NJ: Prentice-Hall, 1977, pp. 1-54. 15 Hertzler, A., and C. Vaughn. The relationship of family structure and interaction to nutrition. Journal of the American Dietetic Association 74:23-32, 1979. 16 Reiss, D., and M. Oliveri. Family paradigm and family coping: A proposal for linking the family's intrinsic adaptive capacities to its responses to stress. Family Relations 29(4):431-44, 1980. 17 Dager, E. Socialization and personality development in the child. In Handbook oJmarriage and theJamily, H. T. Christensen, ed. Chicago: Rand McNally, 1964, pp. 740-81. 18 Garn, S., and D. Clark. Trends in fatness and the origins of obesity. Pediatrics 57:443-56, 1976. 19 Harris, L. and Associates. The Perrier study: fitness in America, New York: Harris, 1979, pp. 6-9. 20 Wakefield, L., and S. Merrow. Interrelationships between selected nutritional, clinical, and sociological measurements of pre-adolescent children from independent low-income families. American Journal of Clinical Nutrition 20:291-302, 1967. 21 Burt, J., and A. Hertzler, Parental influence on the child's food preference. Journal oj Nutrition Education 10:127-28, 1978. 22 Bernard, J. The adjustment of married mates. In Handbook oj marriage and thefamily, H. T. Christensen, ed. Chicago: Rand McNally, 1964, pp. 675-739. 23 Kintner, M., P. Boss, and N. Johnson. The relationship between dysfunctional family environments and family member food intake. Journal of Marriage and the Family 43:633-41, 1981. 24 Bruch, H. Social and emotional factors in diet changes. Journal oj American Dietetics 63:461-70, 1961. 25 Hansen, D., and R. Hill. Families under stress. In Handbook of marriage and the/amily, H. T. Christensen, ed. Chicago: Rand McNally, 1964, pp. 782-819. 26 Ferreira, A. J., and W. D. Winter. Decision-making in normal and abnormal two-child families. Family Process 7:17-36, 1968.

Use of Audiocassettes in a Nutrition Education Program Susan E. Travis1, Royal D. Colle2 , Ardyth H. Gillespie1, and Mary Lou Tenney1 I

Division ofNutritional Sciences and 2Department of Communication Arts, Cornell University, Ithaca, New York 14853

The Expanded Food and Nutrition Education Program (EFNEP) trains paraprofessional aides to help low-income homemakers in their communities improve their families' diets through personal instruction in selecting and preparing nutritious foods. For many EFNEP participants, whether they consume a nutritious diet depends on their ability to manage their resources, including federal assistance from programs such as the Food Stamp Program. EFNEP thus encourages participating families who are eligible, to enroll in the Food Stamp Program and tries to recruit families who are already using food stamps. But the number of families who could benefit from the VOLUME

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Food Stamp Program and from EFNEP's help exceeds EFNEP's capacity for teaching one-to-one or small group sessions. Although the personal instruction traditionally used in EFNEP has been shown to be very effective (1-3), EFNEP needs a supplemental teaching system that is more efficient in recruiting participants and in communicating with a larger audience. Such a system must convey nutrition information without distorting it, make nutrition messages available in circumstances convenient and congenial to the culture and lifestyle of the target audience, and be functional with those in this audience who may not have or use reading skills for acquiring nutrition in-

formation. These considerations have pointed to audiocassette technology as a promising means of communicating nutrition to EFNEP participants, especially if used in conjunction with traditional strategies. Audiocassettes have been used successfully in educational programs for low-income people who were geographically remote or isolated from public assistance programs in informal settings, ranging from Guatemala to Tanzania (4, Note 2). We developed and evaluated a nutrition education program for EFNEP using audiocassettes to reinforce personal instruction (Note 3). The goal ofthe program was to use JOURNAL OF NUTRITION EDUCATION

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