With more than one in four Australian children overweight or obese, and the significant risks this poses for health problems like asthma, depression, diabetes and heart disease, finding effective treatments for childhood obesity is rapidly becoming a national priority.
As part of the effort in this area, we have implemented a community-based intervention helping families manage weight and eating issues. Our evidence-based Healthy Eating and Lifestyle Program (HELP) applies cognitive behavioural principles to the problem, focusing on the mother's role in her child's weight management. It targets overweight or obese mothers with overweight or obese children, using a group format with mothers attending ten weekly sessions. The underpinning logic of the program is that if mothers are better equipped to manage their own weight, they will subsequently be more able to do so in the context of the whole family.
Underpinning the focus on mothers are data from the Western Australian (WA) Childhood Growth and Development Study. These data indicate that a mother's body mass index (BMI) was the strongest predictor of her child's BMI.1 Further, more than 80% of children in the study who were overweight or obese had mothers who were also overweight or obese. This is not altogether surprising, given that mothers are key role models for their children's dietary and exercise behavior, and play an influential role in the areas of cognition and emotion in the areas of eating and weight.
On three occasions between 2009 and 2011, HELP was offered as a free program to families living in a southern metropolitan area of WA. Saturation advertising and promotional methods were used to recruit families. Typically, this involved two weeks of paid advertising along with editorial coverage of HELP in a community newspaper although, on one occasion, an article about the program also appeared in the state's major daily newspaper. On each occasion, program information was sent to local primary schools for inclusion in school newsletters, and advertising flyers were displayed around the local government area in places like schools, shopping centres, medical centres, child health clinics, playgroups, libraries and community centres. Other promotional avenues included a Facebook page, paid advertising through Facebook, and participation in a talkback radio program that discussed issues within the local area. On one occasion, we also advertised a community forum to find out why the first attempt to recruit families to HELP was unsuccessful. This forum was subsequently cancelled due to lack of community interest. Similarly, prior to the development of HELP, this research group previously attempted to run community forums on childhood obesity at primary schools within the same local government area, with no interest from community members.
The promotion of the program also entailed a partnership with community health workers and local government officers, giving emphasis to their potential contribution with recruitment and in providing practical support for local delivery of HELP sessions. Although poorly attended, we also we also ran community forums to introduce HELP and its facilitator to the community prior to program commencement.
Despite this substantial effort to market our program, the response was minimal with only a handful of people ever making email or phone inquiries about participating. Consequently, we have been unable to deliver the ten-session HELP program.
This outcome surprised and puzzled us, not least because of the high prevalence of overweight and obesity in both adults and children, and the almost daily expressions of concern about these issues in the popular media.
In an attempt to find out why we weren't able to enlist families in the program, we conducted two focus groups with nine local community health workers and surveyed parents of primary school children in the area. The response to the parent questionnaire was also poor, with only 50 questionnaires returned (a 2% response rate). Several themes emerged from this research, shedding some light on possible reasons for our lack of recruitment success. The first of these was the issue of mothers being “time poor”, as they attempt to balance home, work and other commitments.
However, the subsequent reasons suggest that many mothers might avoid programs that deal with the issue of overweight and obesity within their family because they associate them with both substantial difficulty with respect to managing dietary change in the family, and an unacceptable level of exposure to personal or family level stigma.
What does our experience and subsequent research tell us about interventions for childhood obesity targeting mothers?
First, it reinforces the point that having an evidence-based intervention is only part of the solution to addressing childhood obesity. Second, it highlights that we know far too little about how we might encourage time-poor mothers to embark on a journey of personal and family level behaviour change that they may find threatening and difficult. Despite the daunting challenge of addressing this, the health costs of failing to find effective strategies appear unacceptable. Upstream solutions seem to offer some hope and we are currently working on some options in this area, however, they will only ever form part of the comprehensive approach often needed to address behaviour-related population health problems. Perhaps this signals that it is time for the type of far-sighted and generous investment of funds in the area of obesity that State and Commonwealth Governments made in dealing with tobacco control in the 1980s and 1990s. Among other things, this could allow public health professionals across Australia the opportunity for rapid, extensive practical ‘intelligence gathering’ about what works in the field, thereby facilitating a timely solution to what has become an obesity epidemic.