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Abstract

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods and Procedures
  5. Results
  6. Discussion
  7. ACKNOWLEDGEMENT
  8. DISCLOSURE
  9. References

Family functioning is found to be associated with overweight and obesity in childhood, but its association with maternal obesity risk behaviors is not clear. This study aimed to investigate whether family functioning is associated with maternal obesity risk behaviors and to inform the development of early obesity interventions. A total of 408 first-time mothers at 24–34 weeks of pregnancy were included in the study. They participated in the Healthy Beginnings Trial (HBT) conducted in southwest Sydney, Australia in 2008. An analysis of cross-sectional baseline data was conducted using ordinal logistic regression modeling. Key measures were assessed using the McMaster Family Assessment Device, and self-reported obesity risk behaviors including excessive consumption of soft drinks, fast food, and excessive small screen time. The study found that 30% of the study population had a family functioning score ≥2, indicating unhealthy family functioning. About one-third (36%) of the mothers had more than one obesity risk behavior. Mothers with a family functioning score ≥2 were more likely to have more than one obesity risk behavior (47% vs. 32%, P < 0.05) than mothers with a lower score. The proportion of mothers with a family functioning score ≥2 increased from 22% to 29% to 39% as the number of maternal obesity risk behaviors increased from 0 to 1 to 2 or more, giving an adjusted proportional odds ratio (AOR) of 2.0 (95% confidence interval (CI) 1.3–3.0, P = 0.001). Family functioning is independently associated with the number of maternal obesity risk behaviors after allowing for the effects of maternal age and education. Overweight and obesity interventions should consider addressing family functioning.


Introduction

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods and Procedures
  5. Results
  6. Discussion
  7. ACKNOWLEDGEMENT
  8. DISCLOSURE
  9. References

Family functioning generally refers to interactions with family members that involve physical, emotional, and psychological activities and affects many aspects of family life including: acceptance of individuals, consensus on decisions, communication, and the ability to solve day-to-day problems (1). It is an important aspect of the family environment that influences the physical, social, and emotional well-being of children (2). Family functioning has become an important public health issue because it is associated with a range of child health and well-being indicators, including physical and mental health, risk behaviors, and developmental, academic, and social outcomes (1,3,4).

The concept of family functioning has been applied in social science and medical research on families of children and adolescents with chronic health conditions (5,6,7,8,9,10). Despite a variety of measurement tools being used, family functioning has consistently been found to be associated with how families deal with health conditions and problematic behaviors of children or adolescents. For example, parents of children with chronic conditions have described their families as lacking family flexibility or having low levels of possibility of changes in the family (5,6). Family functioning is associated with psychological outcomes and metabolic control of children with type 1 diabetes (7,8), child mental health (9), as well as eating behaviors and attitudes (10).

Family functioning is also associated with overweight and obesity in childhood. For example, poorer family functioning scores are correlated with greater BMI in fifth-grade children (11), and families with an overweight child have more maladaptive control strategies and less parental support regarding child eating behavior (12). A recent study examining family functioning and the development of childhood overweight recommended that parenting style and functioning should be promoted to better inform the development of interventions that may help stem the growing prevalence of childhood obesity (13).

However, the role of family functioning in the development of overweight and obesity is less well understood. Excessive consumption of soft drinks and fast food, and excessive small screen time (e.g., TV viewing) are known as obesity risk behaviors (14,15,16,17), but whether these behaviors are related to family functioning is unknown. Currently, around 40% of women of child-bearing age and 20% of children aged 2–3 years are overweight or obese in Australia (18,19). Hence, there is a need for an improved understanding of family functioning and its role in influencing a family's eating and feeding practices and patterns of risk-taking behaviors among mothers, in order to prevent the early onset of childhood overweight and obesity. As mothers can influence a child's weight through specific feeding practices, and perhaps more broadly through their parenting style and management of family functioning, it is important to understand the relationships between family functioning and obesity risk behaviors of mothers.

In addition, maternal obesity risk behaviors are an important determinant of child obesity risk behaviors and hence child obesity are therefore important to examine at baseline. Family functioning and maternal obesity risk behaviors might be related and might then in turn increase the risk of child obesity. For example, perhaps pregnant women who report low levels of family functioning at baseline have higher obesity risk behaviors in part because they lack the skills to organize healthy meals (13) or are unable to plan recreational activities other than watching TV. This inability to organize healthier alternatives would be likely to persist after the child is born, leading to an increased risk of childhood obesity.

The need to enhance family functioning to improve the health status of children and parents is increasingly recognized. In 2008, we commenced the Healthy Beginnings Trial (HBT) to test the effectiveness of an early childhood obesity intervention in the first 2 years of life (20). The intervention uses a home-visiting strategy to promote healthy feeding of babies among first-time mothers. One of the aims of this trial was to improve healthy behaviors of children and mothers by enhancing family functioning and parent-child interaction.

From the literature it remains unclear whether poor family functioning leads to child obesity or having a child with this “chronic illness” puts stress on the family that reduces family functioning. We aim to address this limitation of previous research by first showing a relationship between family functioning and maternal obesity risk behavior, an important precursor of childhood obesity. In our longitudinal study, we will then be able to examine whether family functioning at baseline predicts future obesity (or obesity risk behaviors) and whether an intervention to improve family functioning has any impact on maternal or child obesity risk behaviors.

This article reports on those aspects of the data collected at the baseline interview for the HBT. We aimed, first, to assess the level of family functioning as reported by first-time mothers and, second, to explore the relationship between family functioning and number of obesity risk behaviors of the mothers.

Methods and Procedures

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods and Procedures
  5. Results
  6. Discussion
  7. ACKNOWLEDGEMENT
  8. DISCLOSURE
  9. References

Study design

Although the main study is a randomized controlled trial, the baseline data used in this analysis are considered a cross-sectional survey. The study was conducted in southwest Sydney, Australia in 2008 and approved by the ethics review committee of Sydney South West Area Health Service (RPAH Zone). The details of the HBT research protocol have been reported elsewhere (20). HBT is registered with the Australian Clinical Trial Registry (ACTRNO12607000168459).

Study participants

All pregnant women who attended antenatal clinics of Liverpool and Campbelltown Hospitals, located in south-western Sydney, were approached by research nurses with a letter of invitation and information about the study. Women were eligible to participate if they were aged 16 years and over, were expecting their first child, were between weeks 24 and 34 of pregnancy, were able to communicate in English and lived in the local area. Once eligibility was established and consent obtained, women were asked to fill in a registration form with their contact information to allow the nurses to make further arrangements for baseline data collection.

From around 2,700 mothers who were approached, a total of 667 first-time mothers at 24–34 weeks of pregnancy were recruited for the main study. Four hundred and nine mothers were interviewed at home before giving birth. Another 258 mothers who also participated in the HBT were excluded, as we were not able to conduct the survey before they gave birth. After excluding one mother due to missing value on family functioning, a total of 408 mothers were included in this particular study.

Data collection and key measures

A face-to-face home interview with participating mothers was conducted by one of four research nurses before randomization. The interview took 20–30 min and included a range of standardized questions about the general health, physical activity and nutrition of the mothers, as well as demographic information. The definition of family was based on the respondents' own perception.

Family functioning

We used the Family Assessment Device—General Functioning Scale, a 12-item scale measuring general function of the family, extracted from the McMaster Family Assessment Device (21,22). The Family Assessment Device—General Functioning Scale has been widely used in population surveys for assessing overall family functioning (23). The general functioning scale is recommended as a summary score of family functioning (24), a score ≥2.0 being considered unhealthy (22,24). The validity and reliability of the 12-item general functioning scale have been described by Byles et al. (22).

We calculated the scores, converting all statements to positive form, summing them and dividing by the number of statements with a valid response. This gave a score between one and four, with one representing a healthy functioning family and four reflecting unhealthy family functioning. Unhealthy family functioning includes avoiding discussing concerns or fears, having lots of bad feelings within the family, not being able to turn to each other for support or to confide in each other, not being able to talk about sadness or express feelings to each other, having difficulty in making decisions, not accepting family members as they are, and having difficulty in planning family activities (21).

Maternal obesity risk behaviors

To assess mothers' obesity risk behaviors during pregnancy, we asked a set of questions about dietary behaviors and sedentary behaviors, sourced from the New South Wales Health Survey Program, in the state of New South Wales, Australia (25). These covered time spent in daily small screen recreation (e.g., television viewing) and frequency of consumption of soft drinks, processed meat, meals from fast food outlets or local takeaways, and chips or French fries. The reliability and validity of the survey questions have been demonstrated in an adult population and the questions are widely used in New South Wales population health surveys (25,26,27). The questions used in this study are:

How many cups of soft drink, cordial (concentrated sweet drink), or sports drink, such as lemonade or Gatorade, do you usually drink in a day? (One cup = 250 ml. 1 can of soft drink = 1½ cups. 1 × 500 ml bottle of Gatorade = 2 cups) (Do not include diet drinks)

How often do you have meals or snacks such as burgers, pizza, chicken, or chips from places like McDonalds, Hungry Jacks, Pizza Hut, KFC (Kentucky Fried Chicken), Red Rooster or local takeaway food places?

How often do you eat chips, French fries, fried potato wedges, fried potatoes or crisps?

How often do you eat processed meat products such as sausages, frankfurts, devon (similar to bologna), salami, meat pies, bacon or ham?

On average, how many hours per day or per week do you spend sitting watching television, videos, DVDs, playing computer or video games, or surfing the internet for pleasure?

Mothers were categorized as having each of the obesity risk behaviors if they reported consuming two or more cups of soft drinks per day, two or more fast food meals per week, processed meat two or more times per week, or chips more than two times per week, or having more than 3 h per day on small screen (e.g., TV). Additional analyses found that these maternal obesity risk behaviors predicted maternal obesity (data not shown), some of which were consistent with the findings of other studies (15,16,17).

Sociodemographic characteristics

Age, employment status, education level, marital status, language spoken at home, and country of birth, were obtained using the standard New South Wales Health Survey questions (25).

Analysis

Statistical analyses were carried out using Stata 10 (StataCorp, College Station, TX) (28). Proportions were compared between groups using Pearson's χ2-tests or Mantel-Haenszel χ2-tests for trend in proportions when appropriate.

To examine the factors associated with the number of maternal obesity risk behaviors (0, 1, or ≥2), χ2-tests for trend and ordinal logistic regression modeling were used. Variables with P < 0.25 on bivariate analysis were further entered into the model, then the least significant terms were progressively dropped until only those with P < 0.05 remained. The proportional odds assumption was tested for each variable in the final model and found not to be violated. Adjusted proportional odds ratios (AORs) with 95% confidence intervals (CIs) were calculated as a measure of the associations.

Results

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods and Procedures
  5. Results
  6. Discussion
  7. ACKNOWLEDGEMENT
  8. DISCLOSURE
  9. References

The mothers' ages range from 16 to 46 years with a mean of 26. Most of the mothers (87%) were either married or living with their de facto partner. Twenty three percent had completed tertiary education and 11% spoke a language other than English at home. In addition, 22% were unemployed and 29% had a household income before tax of less than $40,000 per year.

Family functioning and maternal obesity risk behaviors

Table 1 shows distributions of family functioning score, obesity risk behaviors and number of obesity risk behaviors of the 408 participating first-time mothers. Among all participating mothers, the mean and median of family functioning score were 1.67 (s.d. 0.41) and 1.75, respectively. Thirty percent of the families had a family functioning score of two or more. Over a third (36%) of the mothers reported having spent more than 3 h per day on small screen time. It was noted that the distribution of small screen time was skewed. The mothers with low socioeconomic status (e.g., unemployed or less educated) were more likely to spend more time watching TV.

Table 1.  Distributions of family functioning score, obesity risk behaviors and number of obesity risk behaviors of the 408 participating first-time mothers in southwest Sydney, Australia, 2008
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One-third (33%) reported having consumed two or more cups of soft drink per day. About a quarter (26%) reported having consumed fast food and 36% reported having processed meat product two or more times per week, and 28% reported having chips more than two times per week. In addition, 65% of the mothers reported having at least one obesity risk factor, with 22, 11, and 3% of mothers having 2, 3, and 4 obesity risk behaviors, respectively.

Family functioning was not found to be associated with any of these single obesity risk behaviors as shown in Table 2. The mean and median family functioning scores were similar for those with and without each risk behavior.

Table 2.  Family functioning and obesity risk behaviors of the 408 participating first-time mothers in southwest Sydney, Australia, 2008
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Family functioning and the number of maternal obesity risk behaviors

Table 3 shows that family functioning was significantly associated with the number of maternal obesity risk behaviors (trend χ21 = 9.38, P = 0.002). All the other sociodemographic characteristics, apart from language spoken at home, were also associated with the number of obesity risk behaviors.

Table 3.  Family functioning score and sociodemographic characteristics associated with number of obesity risk behaviors in bivariate analysis, with 408 participating first-time mothers in southwest Sydney, Australia, 2008
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Using ordinal logistic regression modeling, family functioning, as well as mother's age and education level, remained significantly associated with the number of obesity risk behaviors (Table 4). The proportion of mothers with a family functioning score of two or more increased from 22% to 29% to 39% as the number of maternal obesity risk behaviors increased from 0 to 1 to 2 or more. The odds of mothers in poorer functioning families having more obesity risk behaviors were twice those of mothers in better functioning families (AOR 2.0, 95% CI 1.3–3.0, P = 0.001). The proportion of mothers aged 25 or over decreased from 70% to 55% to 47% as the number of obesity risk behaviors increased from 0 to 1 to 2 or more. The odds of first-time mothers older than 25 having more obesity risk behaviors were about 3/5 of those of younger mothers (AOR 0.58, 95% CI 0.4–0.9, P = 0.01). The proportion of mothers with tertiary education (equivalent to college or university education in the United States) also decreased from 32 to 19 to 16% as the number of obesity risk behaviors increased from 0 to 1 to 2 or more. The odds of mothers having more obesity risk behaviors decreased with increasing education, those with tertiary education having half the odds of those with ten years of education or less (AOR 0.50, 95% CI 0.3–0.9, P = 0.02).

Table 4.  Factors associated with number of obesity risk behaviors in ordinal logistic regression with 408 participating first-time mothers in southwest Sydney, Australia, 2008
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Discussion

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods and Procedures
  5. Results
  6. Discussion
  7. ACKNOWLEDGEMENT
  8. DISCLOSURE
  9. References

To our knowledge, this study is the first to establish a link between family functioning and the number of obesity risk behaviors (or multiple obesity risk behaviors) among pregnant women. We found that a substantial proportion (30%) of 409 first-time mothers in southwestern Sydney lived in a family with unhealthy family functioning and this proportion increased from 22 to 29 to 39% as the number of maternal obesity risk behaviors increased from 0 to 1 to 2 or more, after adjusting for age and education.

Recognizing the association between family functioning and the number of maternal obesity risk behaviors has implications for family-based interventions aiming to improve family dietary behaviors and tackle childhood obesity. The presence of multiple risk factors generally increases the risk of having a particular health problem, in this case, obesity (29). However, whether improved family functioning can in fact lead to a reduced number of obesity risk behaviors remains to be tested in future research. Our findings suggest that such research should be targeted towards young and less educated mothers.

Our study shows that family functioning is an important correlate of multiple maternal obesity risk behaviors. However, the causal pathway between family functioning and eating and sedentary behaviors is unclear. One possibility is that, under conditions of poor family functioning, people become vulnerable to developing risk behaviors, similar to the effect of family functioning on problematic eating behaviors and attitudes (10). With poor family functioning, mothers could have higher obesity risk behaviors in part because they lack the skills to organize healthy meals (13). Another possibility is that a mother who has herself experienced poor parenting or an impoverished environment as a child, may in turn have less capacity to influence both healthy family functioning and healthy lifestyle behaviors as an adult.

To date, there has been little research on how and to what extent family functioning influences families' health behaviors in everyday life. As demonstrated in this study, without looking into the number of maternal obesity risk behaviors, we would not have found any relation between family functioning and individual risk behavior. This may explain why there is no published research in this area. This also highlights the importance of investigating multiple risk behaviors when examining family functioning and its association with various risk behaviors.

It should be noted that family functioning is a very complex phenomenon which can be assessed in various ways (21), although the broad context of family functioning is similar. For example, the Family APGAR questionnaire measures a subject's satisfaction with five components of family functioning including adaptation, partnership, growth, affection and resolve (30). Other measures of family functioning include the Family Adaptability and Cohesion Scales (31), the Family Environment Scale, which is commonly used in studies of families of children with chronic illness (32), and the Family Assessment Measurement III (33). In this study, we used the Family Assessment Device—General Functioning Scale (21,22), specifically for assessing the general functioning of family. Because of this variety of measurement tools, the results of various studies may not be comparable. A broad theoretical framework for measurement of indicators of family functioning has been recommended for research into family and child health and well-being (2).

Although no studies were identified that specifically examined the relationship between family functioning and parent obesity risk behaviors, previous research has suggested that poorer family functioning is associated with overweight and obesity in children (11,12). It could be expected that children live within a family context that shapes their health behaviors, and their understanding of health and well-being. Poor family functioning may be a predictor of unhealthy parental obesity risk behaviors. Children who grow up in an environment of poor family functioning and unhealthy parental obesity risk behaviors may then be more likely to become obese.

In addition, the study found that women who were younger and less educated were more likely to have more obesity risk behaviors. This is consistent with a previous report in this study population showing less educated women were more likely to have children at younger ages and were less knowledgeable about health recommendations on breastfeeding (34). There are cognitive, social and biological reasons for particular populations (e.g., young and less educated) sharing similar patterns of health risk behaviors (35).

Limitations

Although, this study provides empirical evidence linking family functioning and the number of maternal obesity risk behaviors, there are a number of limitations that have to be addressed. First, due to the nature of a cross-sectional design we cannot infer the direction of the relation between poor family functioning and obesity risk behaviors. As this study is part of the longitudinal HBT, we will have the opportunity to further test whether the association found in the study is causal, and to examine the effect of family functioning on child obesity risk behaviors. Second, although our study had a relatively large sample of 409 first-time mothers, its generalizabilty is still limited due to the locality of the study area. Southwest Sydney is the most socially and economically disadvantaged area of metropolitan Sydney, Australia (22). Third, the measurement tool used for assessing family functioning only assesses the general functioning of the family. Some other aspects of family functioning could be missed. In addition, the assessment of multiple obesity risk behaviors is also limited due to the inclusion of a limited number of risk behaviors.

Implications

Given the findings of the relationship between family functioning and number of maternal obesity risk behaviors, there are a number of important implications for family-based interventions aiming to reduce risk behaviors. Family interventions should not only focus on health-related issues, but should also investigate the family, family structure and environment, and the building of a supportive environment within the family. To improve family functioning, interventions should encourage family members to discuss their concerns or fears, and have a positive feeling within the family, express their feelings to each other and support for each other. In addition, more attention should be given to people with multiple obesity risk behaviors in planning and implementing overweight and obesity interventions. However, to date no interventions of this kind have been implemented. There is a need for more intervention research in this area.

Conclusions

The role of family functioning has been studied extensively in families of individuals with chronic health conditions. It has been suggested that family functioning plays an important role in mediating the family structure and behaviors. In this study, we found that family functioning is independently associated with the number of maternal obesity risk behaviors, after allowing for the effects of maternal age and education.

This suggests that interventions targeting family functioning could potentially lead to a reduced number of mothers having multiple obesity risk behaviors, and therefore reduce overweight and obesity of first-time mothers. Family-based overweight and obesity interventions need to take into account the role of family and family functioning as well as considering multiple obesity risk behaviors.

ACKNOWLEDGEMENT

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods and Procedures
  5. Results
  6. Discussion
  7. ACKNOWLEDGEMENT
  8. DISCLOSURE
  9. References

This is part of the Healthy Beginnings Trial funded by the Australian National Health and Medical Research Council (ID number: 393112). We sincerely thank the Associate Investigators, Prof. Anita Bundy, Dr Lynn Kemp and the members of the steering committee and working group for their advice and support. We wish to thank all the families for their participation in this study. We also thank members of the project team including Karen Wardle, Carol Davidson; Cynthia Holbeck; Dean Murphy; Lynne Ireland, Brooke Dailey, Kim Caines, and Angela Balafas. In addition, we wish to thank James Kite, and Therese Carroll for their support in setting up the database and Hui Lan Xu for assisting with data entry and analysis.

References

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods and Procedures
  5. Results
  6. Discussion
  7. ACKNOWLEDGEMENT
  8. DISCLOSURE
  9. References
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